GERD & PUD

Question 1

is reflux of gastric contents into the esophagus normal?

Answer 1

yes!

Question 2

how is GERD defined as? do there need to be lesions in order to dx GERD? how do the majority of pts w/GERD present on endoscopy?

Answer 2

reflux leading to sxs, eso muscoal injury or both
there do not need to be lesions in order to dx GERD
majority of pts w/GERD show no abn on upper endoscopy

Question 3

what 4 tests can you use to dx GERD?

Answer 3

EGD
esophageal manometry
24 hr pH testing
gastric emptying study

Question 4

typical sxs of GERD?

Answer 4

heartburn

regurgitation

Question 5

define functional heartburn

Answer 5

sxs of heartburn are present w/o evidence of reflux

Question 6

9 GERD extraesophageal sxs

Answer 6

hoarseness
cough
asthma
pharyngitis
sinusitis
pulmonary fibrosis
tonsillar fibrosis
recurrent otitis media
sleep apnea

Question 7

when can one experience transient lower esophageal sphincter relaxations and what can it lead to?

Answer 7

increase in intra-abdominal pressure can overpower a hypotensive LES and lead to reflux during TLESRs
it is more common to occur for reflux to occur in TLESRs which is triggered by gastric distension and serve to enable gas to vent from the stomach

Question 8

how long do TLESRs last for?

Answer 8

for about 20 secs

last significantly longer than the typical primary peristaltic wave

Question 9

what 7 situations can lead to reflux sxs?

Answer 9

visceral hypersensitivity
delayed gastric emptying
hiatal hernia
decreased defenses
impaired esophageal clearance
bacterial overgrowth
reduced LES pressure

Question 10

what are the 3 types of heartburn/reflux?

Answer 10

acid reflux
“neutral” reflux
functional heartburn

Question 11

how can PPIs lead to both GERD and DGER?

Answer 11

PPIs lead to weakly acidic reflux which leads to dilated intercellular spaces and persistent heartburn sxs

Question 12

what 3 physical settings can lead to GERD, erosive esophagitis or NERD?

Answer 12

sustained esophageal contractions
esophageal visceral hypersenstivity
abnormal tissue resistance

Question 13

what can GERD sxs be exacerbated by?

Answer 13

CRAP
C: coffee, cigarettes, chocolate
R: refined carbs, carbs in general, rxs
A: acid foods, alcohol, allergic foods
P: pop, peppermint, packing food in at bedtime, progesterone

Question 14

what kind of drugs can lead to GERD?

Answer 14

antibiotics (tetracycline)
bisphospohates (alendronate, ibandronate, risedronate)
iron supplements
quinidine
pain relievers (ibuprofen, aspirin)
potassium supplements
anticholinergics
tricyclic antidepressants
calcium channel blockers and nitrates used for high blood pressure and heart dz
narcotics (codeine, those containing hydrocodone and acetaminophen)
progesterone
quinidine
sedatives or tranquilizers (benzodiazepines, diazepam, temazepam)
theophylline

Question 15

what %age of adults with NERD do not have relief of sxs with anti-reflux medications?

Answer 15

over 40% do not respond to standard medical anti-reflux tx

Question 16

what is significantly increased following the use of acid suppression therapies? what other dz can this dz play a potential role in developing?

Answer 16

non-acid reflux
widespread use of acid suppression and the development of non-acid reflux can potentially play a role for developing idiopathic pulmonary fibrosis

Question 17

what are some great supplements to help relieve heartburn?

Answer 17

aloe vera leaf inner fillet extract
glutamine
glycine
N-acetyl glucosamine
gamma oryzanol
deglycyrrhized licorice root
d-limonene
zinc carnosine

Question 18

what is David Lamson’s protocol for heartburn? (2 fold)

Answer 18

1. decrease irritative products of fermentation by taking pancreatic enzymes with meals and betaine HCl if indicated
2. improve tone of sphincters, mucosal health and GI motility with phosphatidylcholine (420 mg BID) and if that doesn’t work add Huperzine 50 mg BID

Question 19

what 4 dietary factors could you prescribe to improve gastric emptying? (16 overall)

Answer 19

adequate hydration
eat smaller meals more often
reduce intake of insoluble dietary fiber
reduce foods high in fat
avoid red meat 
reduce protein content of dinner
reduce quantity of food at dinner
reduce alcohol consumption
improve glucose regulation
avoid broccoli and cabbage
gluten-free diet
low carb diet 
aloe juice
papain (super papaya enzyme plus)
organotherapy (nervium vagum)
improve or replace HCl and pepsin output

Question 20

what are 3 ‘exercises’ one could do to tx gastroparesis?

Answer 20

1. contract and relax the abdominal muscles w/regular rhythm immediately after meals (work up to 100 reps/meal)
2. flex and extend the abdomen (sitting or standing) 20 x’s pc
3. chew gum for 1st hr after meals to increase production of saliva, stimulate SM contraction and relax the pylorus

Question 21

7 homeopathics that could be helpful with GERD?

Answer 21

phosphorous
sulphur
robinia
arsenicum
capsicum
carbo veg
nux vom

Question 22

if you have a pt w/pyrosis and suspect serious pathology what are your next steps?

Answer 22

EGD and a barium study

Question 23

if you have a pt w/pyrosis and want to evaluate pancreatic fxn what do you do? what if their levels are low?

Answer 23

stool chymotrypsin

if low dx w/pancreatic insufficiency

Question 24

if you have a pt w/pyrosis what 3 possible dz causing process do you want to r/o? how would you determine each?

Answer 24

SIBO (breath test, serum TTG, AGA, DGP)
hiatal hernia (imaging, reflex and muscle test)
food sensitivities, gluten or lactose intolerance (elimination diet, IgE/IgG, EAV/Caroll)

Question 25

if you have a pt w/pyrosis and want to evaluate gastric pH what are 3 ways you can do that and what are 3 possible results? what might you also evaluate at this time? how would you do this?

Answer 25

can do Heidelberg, string test or trial could have hypo/achlorhydria, euchlorhydria or hyperchlorhydria at this time you would want to evaluate GI flora including H. pylori (H. pylori breath test, stool ag testing, salivary ab testing SIBO breath test)

Question 26

13 H. pylori associated dzs?

Answer 26

``` peptic ulcer atrophic gastritis gastric adenocarcinoma gastric lymphoma (Maltoma) metabolic syndrome CAD atherosclerotic stroke pancreatic adenocarcinoma iron deficiency anemia immune thrombocytopenic purpura chronic urticaria other skin dzs like rosacea hyperemesis gravidarum ```

Question 27

7 dzs inversely associated w/H. pylori?

Answer 27

``` GERD & BE esophageal adenocarinoma asthma, eczema, rhintis fatal cardiovascular events laryngeal carcinoma Crohn's dz Obesity (?) ```

Question 28

depending where H. pylori is growing in the stomach, what are 3 ways H. pylori overgrowth can affect stomach acid concentrations?

Answer 28

antral infxn: hyperchlorhydria asx carrier: euchlorhydria pangastritis: atrophy and hypo/achlorhydria

Question 29

if a pt presents w/PUD what are you specifically going to test for? if they are (-) for that, then what should you suspect as a possible cause?

Answer 29

test for H. pylori | if (-) for H. pylori then ask about medication use, esp NSAIDs

Question 30

what are 3 tx options besides GERD tx options, which you could use to tx PUD?

Answer 30

robert's formula- 2 caps ac and hs cabbage juice (work up to 1-2 pints/d for up to 6 weeks counseling, stress management, etc.

Question 31

what is Dr. Thad Jacob's protocol for treating H. pylori PUD?

Answer 31

``` mastica 1000 mg tid garlic extract 300 mg tid lactoferrin 100 mg tid probiotics 5 Billion tid NAC 500-600 mg BID give all for at least 30 d ```

Question 32

if a pt has drug resistant H. pylori PUD what can you consider adding? what is the mechanism of this added supplement?

Answer 32

add NAC 500-600 mg bid | helps break down biofilm essential to maintenance of H.pylori drug resistance

Question 33

H. pylori triple therapy plus

Answer 33

``` OCAL for 7 days: omeprazole 20 mg bid clarithromycin 500 mg bid amoxicillin 1000 mg bid lactoferrin 900 mg hs probiotic NAC 500-600 mg bid starting one week prior to rx above OCML (if pt is allergic to penicillin) for 7 days: omeprazole 20 mg bid clarithromycin 500 mg bid metronidazole or tinidazole 500 mg bid lactoferrin 900 mg hs probiotic NAC 500-600 mg bid starting one week prior to rx ```

Question 34

what is in the 1 d protocol?

Answer 34

omeprazole 40 mg bismuth subcitrate 240 mg x 4 amoxicillin suspension 2000 mg x 4 metronidazole 500 mg x 4

Question 35

what %age of pts who experienced H. pylori eradication became re-infected and had a PUD dx again and w/in what time frame?

Answer 35

7.6% were re-infected and became dx w/PUD

Question 36

what are 11 natural alternatives for H. pylori eradication?

Answer 36

``` mastic gum water garlic glycyrrhiza lactoferrin wasabi cabbage trachypsermum copticum, xanthium basilicum, pumbago zeylanica probiotics propilis and ginger lycopene ```