NSG./533./Advanced./Pharm./Exam./1
1. GERD./physiology:./Lower./esophageal./sphincter./dysfunction./(LES)-
./ transient./relaxtions,./low./tone./Hiatal./hernia=promotes./reflux
Delayed./gastric./emptying/increased./intra./ab./pressure:./obesity,./pregnancy
Injury./is./from./acid+pepsin./exposure./to./esophageal./mucosa-severity./relates./to./exposure./time./+clearance
2. What. / worsens. / GERD:. / ETOH,./smoking,./obesity,./late./meals,./large/fatty./meals
catteine,./chocolate/peppermint./may./reduce./LES./tone-
Peppermint./may./worsen./reflux./by./relaxing./LES./MEDS./that./worsen:./anticholinergics,./CCB,./nitrates,./theophy
./
lline,./progesterone
3. symptoms./of./GERD:./typical:./heartburn,./regurgitation
atypical:./ chronic./ cough,./ hoarseness,./ asthma./ like./ symptoms
ALARM:./dysphagia,./odynophagia,./wt./loss,./GI./bleed./anemia./alarm
=./endoscopy,./not./OTC./trial
4. when./to./test./vs./tx./GERD:./uncomplicated./GERD-
>./empiric./PPI./trial./8./wk./Alarm./or./refractory./GERD-->./EGD
Persistent./symptoms./despite./PPI-->./pH./monitioring,./manometry
5. PPI. / risks:. / Increased./risk./of./fractures./(postmenopausal./women)./pneumonia,./C./ditt,./hypomagnesemia,./B12./and./ir
on./malabsorption,./atrophic./gastritis,./kidney./disease
6. Non-
pharm./interventions./for./all./GI./conditions:./Diet+trigger:./greasy/spicy./foods,./ETOH,./catteine;./l
actose/FODMAPS./is./IBS./type./symptoms
hydration./tobacc
o./cessation./wt./m
, NSG./533./Advanced./Pharm./Exam./1
gmt
, NSG./533./Advanced./Pharm./Exam./1
meds./reveiw:./remove/replace./ottending./meds./when./possible-./NSAIDs,./iron,./opiods,./anticholinergics.
When./to./refer/escalate:./alarm./symptoms./(GI./bleed,./wt./loss,./progressive./dysphagia,./severe./dehydration,./persistent./vo
miting,./severe./ab./pain
7. GERD./pharmacology:./Antacids-
PRN./fastest./relief./neutralize./acid:./short./duration
counseling:./separate./from./other./meds./(chelation/absorption./issues)./TUM
S./(calcium./carbonate):./highest./acid./neutralizing,./rapid
Risks:./hypercalcemia,./constipation./(Al),./kidney./stones./(Ca),./diarrhea./(Mg)
H2./receptor./antagonist./(H2RAs)
good./for./mild/intermittent./symptoms,./nocturnal./symptoms
less./potent./that./PPIs./for./healing/maintenance./of./erosive./disease
PEPCID./(famotidine):./most./potent,./+Nocturnal,./fewer./interactions./than./cimetidine./(CYP),./longer./duration./of./action,./min.
/CNS./ettects
PPIs
MOST./ettective./acid./suppression./+./best./for./esophagitis./healing./and./maintenance./Tak
e./before./meals./(30-60./min./before./breakfast)
PANTOPRAZOLE./(safest):./preferred./when./on./clopidogrel,./fewer./interactions./OMEPRAZOLE/ESOMEPRAZOL
E:./most./potent,./part./of./H.pylori./regimen--decreases./clopidogrel./activation
-long./term./PPI-Bad./bones./&./bugs./(fractures,./cditt,./low./mg/b12)
Mild./intermittent./symptoms?./’Antacid./or./H2RA./E
rosive./GERD./or./ulcers?./’PPI
On./clopidogrel?./’Pantoprazole./Nee
ds./rapid./relief?./’Antacid./Needs./he
aling?./’PPI
8. Why./is./self./directed./GERD./therapy./(OTC)./limited./to./2./weeks:./avoid./masking./ALarm./sy
mptoms:./cancer,./erosive./disease,./bleeding,./strictures
prevent./inappropriate,./prolonged./used./without./diagnosis/monitoring
, NSG./533./Advanced./Pharm./Exam./1
9. PUD./causes:./MOST./COMMON
H../pylori./(chronic,./recurrent)./NSAI
Ds./(often./silent-->./bleed)
Stress-related./mucosal./damage./(SRMD)./(ICU./patients)
Other:
Zollinger-Ellison./(gastrinoma)
smoking-mucosal./injury,./decreases./protective./prostaglandins,./increases./pepsin)
10. Zollinger-Ellison./Syndrome./(ZES):./ZES./-->./Peptic./Ulcer./Disease
Pathophys./=./gastrin-secreting./tumors./(gastrinomas)./within./GI./tract./-->./hypersecretion./of./gastric./acid
FOILS:
(1) Pheochromocytoma. / -->. / HTN
(2) Carcinoid./Syndrome./--
>./tricuspid./and./pulmonary./valve./abnormalities,./flushing,./bronchoconstriction,./severe./diarrhea
11. Risk./factors./for./NSAID./ulcer:./>65./yo./a
nticoagulants
coagulopathy./ste
roids
prior./PUD/bleed./comormi
d./disease
multiple./NSAIDs./(including./ASA)./lo
ng./duration
high./dose
12. Prevention./of./NSAID./ulcer./if./NSAID./must./continue:./PPI./prophylaxis./(standard./dose./4-
8./wks):./reduces./risk./and./better./tolerated./than./misoprostol
Misoprostol:./200mcg./QID./prevents./complications./but./has./lots./of./GI./side./ettects./and./CONTRAINDICATED./PREGNANCY
H2RAs:./less./ettective
13. NSAID./induced./ulcer./treatment:./*./test./for./H./pylori
*./dc./the./NSAID
1. GERD./physiology:./Lower./esophageal./sphincter./dysfunction./(LES)-
./ transient./relaxtions,./low./tone./Hiatal./hernia=promotes./reflux
Delayed./gastric./emptying/increased./intra./ab./pressure:./obesity,./pregnancy
Injury./is./from./acid+pepsin./exposure./to./esophageal./mucosa-severity./relates./to./exposure./time./+clearance
2. What. / worsens. / GERD:. / ETOH,./smoking,./obesity,./late./meals,./large/fatty./meals
catteine,./chocolate/peppermint./may./reduce./LES./tone-
Peppermint./may./worsen./reflux./by./relaxing./LES./MEDS./that./worsen:./anticholinergics,./CCB,./nitrates,./theophy
./
lline,./progesterone
3. symptoms./of./GERD:./typical:./heartburn,./regurgitation
atypical:./ chronic./ cough,./ hoarseness,./ asthma./ like./ symptoms
ALARM:./dysphagia,./odynophagia,./wt./loss,./GI./bleed./anemia./alarm
=./endoscopy,./not./OTC./trial
4. when./to./test./vs./tx./GERD:./uncomplicated./GERD-
>./empiric./PPI./trial./8./wk./Alarm./or./refractory./GERD-->./EGD
Persistent./symptoms./despite./PPI-->./pH./monitioring,./manometry
5. PPI. / risks:. / Increased./risk./of./fractures./(postmenopausal./women)./pneumonia,./C./ditt,./hypomagnesemia,./B12./and./ir
on./malabsorption,./atrophic./gastritis,./kidney./disease
6. Non-
pharm./interventions./for./all./GI./conditions:./Diet+trigger:./greasy/spicy./foods,./ETOH,./catteine;./l
actose/FODMAPS./is./IBS./type./symptoms
hydration./tobacc
o./cessation./wt./m
, NSG./533./Advanced./Pharm./Exam./1
gmt
, NSG./533./Advanced./Pharm./Exam./1
meds./reveiw:./remove/replace./ottending./meds./when./possible-./NSAIDs,./iron,./opiods,./anticholinergics.
When./to./refer/escalate:./alarm./symptoms./(GI./bleed,./wt./loss,./progressive./dysphagia,./severe./dehydration,./persistent./vo
miting,./severe./ab./pain
7. GERD./pharmacology:./Antacids-
PRN./fastest./relief./neutralize./acid:./short./duration
counseling:./separate./from./other./meds./(chelation/absorption./issues)./TUM
S./(calcium./carbonate):./highest./acid./neutralizing,./rapid
Risks:./hypercalcemia,./constipation./(Al),./kidney./stones./(Ca),./diarrhea./(Mg)
H2./receptor./antagonist./(H2RAs)
good./for./mild/intermittent./symptoms,./nocturnal./symptoms
less./potent./that./PPIs./for./healing/maintenance./of./erosive./disease
PEPCID./(famotidine):./most./potent,./+Nocturnal,./fewer./interactions./than./cimetidine./(CYP),./longer./duration./of./action,./min.
/CNS./ettects
PPIs
MOST./ettective./acid./suppression./+./best./for./esophagitis./healing./and./maintenance./Tak
e./before./meals./(30-60./min./before./breakfast)
PANTOPRAZOLE./(safest):./preferred./when./on./clopidogrel,./fewer./interactions./OMEPRAZOLE/ESOMEPRAZOL
E:./most./potent,./part./of./H.pylori./regimen--decreases./clopidogrel./activation
-long./term./PPI-Bad./bones./&./bugs./(fractures,./cditt,./low./mg/b12)
Mild./intermittent./symptoms?./’Antacid./or./H2RA./E
rosive./GERD./or./ulcers?./’PPI
On./clopidogrel?./’Pantoprazole./Nee
ds./rapid./relief?./’Antacid./Needs./he
aling?./’PPI
8. Why./is./self./directed./GERD./therapy./(OTC)./limited./to./2./weeks:./avoid./masking./ALarm./sy
mptoms:./cancer,./erosive./disease,./bleeding,./strictures
prevent./inappropriate,./prolonged./used./without./diagnosis/monitoring
, NSG./533./Advanced./Pharm./Exam./1
9. PUD./causes:./MOST./COMMON
H../pylori./(chronic,./recurrent)./NSAI
Ds./(often./silent-->./bleed)
Stress-related./mucosal./damage./(SRMD)./(ICU./patients)
Other:
Zollinger-Ellison./(gastrinoma)
smoking-mucosal./injury,./decreases./protective./prostaglandins,./increases./pepsin)
10. Zollinger-Ellison./Syndrome./(ZES):./ZES./-->./Peptic./Ulcer./Disease
Pathophys./=./gastrin-secreting./tumors./(gastrinomas)./within./GI./tract./-->./hypersecretion./of./gastric./acid
FOILS:
(1) Pheochromocytoma. / -->. / HTN
(2) Carcinoid./Syndrome./--
>./tricuspid./and./pulmonary./valve./abnormalities,./flushing,./bronchoconstriction,./severe./diarrhea
11. Risk./factors./for./NSAID./ulcer:./>65./yo./a
nticoagulants
coagulopathy./ste
roids
prior./PUD/bleed./comormi
d./disease
multiple./NSAIDs./(including./ASA)./lo
ng./duration
high./dose
12. Prevention./of./NSAID./ulcer./if./NSAID./must./continue:./PPI./prophylaxis./(standard./dose./4-
8./wks):./reduces./risk./and./better./tolerated./than./misoprostol
Misoprostol:./200mcg./QID./prevents./complications./but./has./lots./of./GI./side./ettects./and./CONTRAINDICATED./PREGNANCY
H2RAs:./less./ettective
13. NSAID./induced./ulcer./treatment:./*./test./for./H./pylori
*./dc./the./NSAID
