SAQ1

Question 1

A 30 year old man presents with a bitter taste in his mouth and a burning sensation in his throat which is worsened by lying down. He also complains of difficulty swallowing. On examination, you identify enamel erosion in his mouth. He smokes regularly and drinks alcohol with his meal every night.

What is the most likely diagnosis for this patient and (if any) what investigations would be indicated and why?

Answer 1

GORD

Investigation - OGD due to dysphagia (red flag)

Question 2

Considering the most likely diagnosis for this patient, if proven correct, what treatment would be indicated?

Answer 2

Lifestyle changes

• stop smoking/drinking
• avoid spicy/greasy foods

Medication
Full dose PPI for 4-8 weeks (omeprazole)

Question 3

This patient comes back to the GP presenting with the same complaints. You had already started him on the first-line treatment for proven GORD. What would be your next steps for this patient?

Answer 3

re-iterate importance of lifestyle advice
check adherence
prescribe an H2RA (e.g.- ranitidine)

Question 4

What are examples of PPIs?

Answer 4

ENDS IN PRAZOLE

Omeprazole
Lansoprazole
Pantoprazole

Question 5

What is the MOA of PPIs?

Answer 5

• H+/K+-ATPase proton pump is responsible for secreting H+ and generating gastric acid
• PPIs irreversibly inhibit the H+/K+-ATPase in gastric parietal cells
• Targets final stage of gastric acid production = suppresses gastric acid production almost completely

Question 6

What are the common adverse effects of PPIs?

Answer 6

GI disturbances

Headaches

Question 7

Scenario - this patient requries PPI - they are also currently taking ramipril and clopidogrel. What PPI would you give to them and why?

Answer 7

NOT OMEPRAZOLE

use either lansoprazole or pantoprazole

Question 8

This patient will most likely require long term use of PPIs - what is the risk of this and what monitoring is required in this case?

Answer 8

long term PPI use can cause hypomagnesaemia - if severe can lead to tetany and ventricular arrhythmia

check serum magnesium before and during treatment

Question 9

What is an example of an H2RA?

Answer 9

Ranitidine

Question 10

What is the MOA of H2RAs?

Answer 10

Histamine is released by local paracrine cells and binds to H2 receptors on gastric parietal cells - this subsequently activates the proton pump to secrete acid

Histamine H2-receptor antagonists reduce gastric acid secretion by blocking the H2-receptors

note: however, the proton pump can also be stimulated by other pathways - therefore H2 receptor antagonists cannot COMPLETELY suppress gastric acid production (unlike PPIs which target the final stage of gastric acid production)