Heartburn

Question 1

Definition of heartburn:

Answer 1

burning sensation in the stomach or lower chest that rises up toward neck and occasionally to the back

Question 2

Heartburn is described as…

Answer 2

• indigestion
• sour stomach
• bitter belching

Question 3

Heartburn is a common symptom of…

Answer 3

gastroesophageal reflux disease (GERD)

Question 4

Dyspepsia is…

Answer 4

• feeling full after eating a small amount of food
• epigastric pain
• epigastric burning

Question 5

Pathophysiology of heartburn and dyspepsia:

Answer 5

esophageal defense mechanisms to help protect mucosa from damage

Question 6

Lower esophageal sphincter (LES) provide a…

Answer 6

physical barrier against gastric contents being refluxed into the esophagus

Question 7

LES will relax when…

Answer 7

one is swallowing to allow things to go into the stomach

Question 8

Risk factors for heartburn:

Answer 8

• food
• lifestyle
• medications
• medical conditions

Question 9

Why are chocolate, peppermint, and fatty food a risk factor for heartburn?

Answer 9

they decrease LES pressure, which leads to increased reflux

Question 10

Why are citrus, tomato-based, and spicy foods a risk factor for heartburn?

Answer 10

they can irritate inflamed esophageal mucosa

Question 11

How does smoking contribute to heartburn?

Answer 11

it relaxes LES pressure and decreasing salivation

Question 12

How does obesity contribute to heartburn?

Answer 12

it increases intra-abdominal pressure

Question 13

What are some lifestyle risk factors, excluding smoking and obesity?

Answer 13

• tight fitting clothes
• lying on your back
• stress
• pregnancy

Question 14

Which medications decrease LES pressure and increase reflux?

Answer 14

• theophylline
• morphine
• Ca2+ channel blockers
• diazepam

Question 15

Which medications can cause dyspepsia through direct gastric mucosal injury, or changes to GI function?

Answer 15

• iron
• antibiotics
• narcotics
• digoxin
• estrogens
• theophylline
• NSAIDs

Question 16

What medical conditions contribute to heartburn?

Answer 16

• motility disorders
• PUD
• Zollinger-Ellison syndrome

Question 17

Heartburn is more frequently noted within…

Answer 17

one hour after eating

- especially after a large meal or indigestion

Question 18

Why does lying down or bending over make heartburn worse?

Answer 18

it can cause regurgitation, which allows acidic fluid in back of throat
- no abdominal contractions

Question 19

If you have heartburn that occurs two or more times, then it is suggestive of…

Answer 19

GERD

Question 20

Exclusions to self treatment:

Answer 20

• dysphagia: difficulty swallowing
• odynophagia: painful swallowing
• upper GI bleeding
• unexplained weight loss
• continuous nausea, vomiting, or diarrhea
• severe stomach pain
• chest pain or shoulder, arm, or neck pain (sign of heart attack)
• heartburn or dyspepsia for > 3 months

Question 21

Types of pharmacologic treatments:

Answer 21

• antacids
• histamine type 2 receptor antagonists (H2RAs)
• combo of antacid and H2RA
• proton pump inhibitors (PPI)

Question 22

Antacids and H2RAs are recommended for individuals with…

Answer 22

mild, infrequent heartburn and dyspepsia

Question 23

Antacids provide…

Answer 23

rapid relief of symptoms w/in 5 minutes

Question 24

Antacids lasts for…

Answer 24

20-30 minutes

Question 25

H2RAs are preferred to an antacid when individuals with mild-moderate heartburn need...

Answer 25

more prolonged relief of symptoms

Question 26

Onset of H2RAs:

Answer 26

30-45 minutes | - longer than antacids

Question 27

Duration of H2RAs:

Answer 27

4-10 H

Question 28

How can H2RAs be used to prevent heartburn?

Answer 28

should be taken 30 min to 1 hr before anticipation of heartburn

Question 29

What is the benefit to combo products?

Answer 29

there is quick relief along with longer duration of action

Question 30

Onset of combo product:

Answer 30

less than 5 min

Question 31

Duration of combo product:

Answer 31

8-10 H

Question 32

When do you use PPIs?

Answer 32

frequent heartburn or when patients don't respond to H2RAs

Question 33

PPIs should be limited to a duration of...

Answer 33

14 days and retreatment to every 4 months

Question 34

Onset of PPIs:

Answer 34

2-3 H

Question 35

Duration of PPIs:

Answer 35

12-24 H | - first time might need up to 4 days for complete relief of symptoms

Question 36

What are non-pharmacologic therapies for heartburn?

Answer 36

dietary and lifestyle modifications

Question 37

Examples of dietary and lifestyle modifications:

Answer 37

- weight loss if overweight - wear loose-fitting clothing - elevate head of bed - eat smaller meals - don't eat within 3 H of going to bed/lying down - limit alcohol and caffeine

Question 38

Dosing of antacids can be repeated within...

Answer 38

1-2H if need be

Question 39

Antacids contain at least one of the following salts:

Answer 39

- magnesium - aluminum - calcium carbonate - sodium bicarbonate

Question 40

Antacids with magnesium can lead to...

Answer 40

dose related diarrhea

Question 41

Antacids with aluminum can lead to...

Answer 41

dose related constipation | - can lead to hypophosphatemia

Question 42

Antacids with calcium can lead to...

Answer 42

constipation

Question 43

Antacids with sodium bicarbonate can lead to...

Answer 43

fluid overload

Question 44

Which have a faster onset, liquid or tablet antacids?

Answer 44

liquid antacids b/c they're already dissolved and provide maximal surface area for action

Question 45

Antacids can potentially decrease absorption of medications such as...

Answer 45

- iron - azithromycin - fluoroquinolones - tetracyclines - ketoconazole - should separate doses by 2 H

Question 46

Examples of antacids:

Answer 46

- alka-seltzer: sodium bicarb - mylanta: magnesium+aluminum or calcium - tums: calcium carbonate - rolaids: calcium+magnesium

Question 47

T/F: H2RAs should be taken every day

Answer 47

F, should take it PRN b/c tolerance can develop

Question 48

Which H2RA should you avoid?

Answer 48

cimetidine (Tagamet) b/c several drug interactions

Question 49

Examples of H2RAs:

Answer 49

- famotidine - ranitidine - cimetidine

Question 50

PPIs are considered a...

Answer 50

last resort

Question 51

Since PPIs inhibit proton pumps that actively secrete acid, PPIs would be most effective when taken...

Answer 51

30-60 min before meal, preferably before breakfast

Question 52

Self treatment with PPIs should be limited to...

Answer 52

14 days and no more frequently than every 4 months

Question 53

Chronic use of PPIs has the potential to...

Answer 53

impair natural defenses and increase risk of infection

Question 54

PPIs can cause reduced gastric acid secretion, which can decrease...

Answer 54

calcium absorption

Question 55

Decreased calcium absorption leads to...

Answer 55

increased bone fractures > 50 YO

Question 56

Calcium citrate is the preferred calcium supplement form for patients on PPIs b/c...

Answer 56

it doesn't require acid environment for dissolution

Question 57

Examples of PPIs:

Answer 57

- omeprazole - lansoprazole - esomeprazole

Question 58

Dosage for all PPIs:

Answer 58

1 capsule 30-60 minutes before morning meal and take QD for 14 days

Question 59

If under 2 YO w/ mild infrequent heartburn, they can take...

Answer 59

calcium carbonate containing antacids

Question 60

H2RAs are indicated for patients ages...

Answer 60

12 YO and older

Question 61

PPIs are indicated for patients ages...

Answer 61

18 YO and older

Question 62

Patients with decreased renal function should be cautioned about using...

Answer 62

aluminum and magnesium antacids, PPIs | - if H2RAs is appropriate, then lower dose should be selected

Question 63

Pregnant women should initially try...

Answer 63

dietary and lifestyle modifications

Question 64

What are some medically safe options for pregnant women?

Answer 64

- calcium and magnesium containing antacids - ranitidine - omeprazole - esomeprazole