Gastroesophageal Reflux Disease (GERD)

What is it and what is used to treat it?

Inflammation of the esophageal mucosa caused by reflux of acid content into the esophagus. It's a chronic disorder that requires continuous care.

H₂ blockers: ranitidine (Zantac) and
PPIs: omeprazole (Prilosec), lansoprazole (Prevacid), rabeprazole (Aciphex), pantoprazole (Protonix), or esomeprazole (Nexium)

*A PPI relieves symptoms faster and maintains healing better than H₂ blocker.

What are some nonpharmacologic measures to manage peptic ulcer and GERD?

1. Avoid tobacco and alcohol
2. Lose weight
3. Avoid hot, spicy, greasy foods
4. Take NSAIDs & glucocorticoids with food
5. Raise the head of the bed
6. Don't eat just before going to bed
7. Wear loose fitting clothes

What are the 7 groups of antiulcer drugs?

1. tranquilizers
2. anticholinergics
3. antacids
4. H₂ blockers
5. PPIs
6. pepsin inhibitor sucralfate
7. prostaglandin E₁ analogue misoprostol

Antiulcer Drugs:

Tranquilizers

Examples and how they work?

• Librax

They have minimal effect in preventing and treating ulcers; however, they reduce vagal stimulation and decrease anxiety.

Antiulcer Drugs:

Anticholinergics

Examples and how they work?

• clidinium bromide and chlordiasepoxide HCl
• glycopyrrolate (Robinul)
• propantheline bromine (Pro-Banthine)

They work by decreasing acetylcholine by blocking the cholinergic receptors and delaying gastric emptying time. Pro-Banthine INHIBITS gastric secretions.

Should be taken before meals. Antacids should be taken 2 h after.

Antiulcer Drugs:

Anticholinergics

Side Effects/Adverse Reactions

Many side effects, including:

• dry mouth
• headache
• blurred vision
• urinary retention
• constipation

Antiulcer Drugs:

Antacids

Examples and how they work

• Sodium bicarbonate (Alka-Seltzer)
• Calcium Carbonate (Tums)
• Magnesium hydroxide
• aluminium hydroxide (Amphojel)
• Mylanta Gas, Maalox Antigas (contains mag. hyroxide and aluminium hydroxide), Mylicon

They work by neutralizing gastric acid. Tums can cause acid rebound. Magnesium hydroxide can cause diarrhea. Aluminium hydroxide can cause constipation.

Antiulcer Drugs:

Antacids

When to take them?

1-3 hours after meals (maximum acid secretion occurs after eating) and at bedtime. Take with 2-4 oz. of water to ensure that the drug reaches the stomach; however, no more than 4 oz. of water should be taken, because water quickens gastric emptying time.

Antiulcer Drugs:

Histamine₂ Blockers

Examples and how they work?

• cimetidine (Tagamet) (has the most side effects)
• famotidine (Pepcid)
• nizatidine (Axid)
• ranitidine (Zantac)

They work by blocking the H₂ receptors of the parietal cells in the stomach, thus reducing gastric acid secretion.

Antiulcer Drugs:

Histamine₂ Blockers: famotidine (Pepcid)

Is 50-80% more potent than cimetidine (Tagamet) and is 5-8 times more potent that ranitidine (Zantac). It is indicated for short term use (4-8 weeks) for the treatment of duodenal ulcer and for Zollinger Ellison syndrome.

side effects include: headache, dizziness, constipation, puritis, decreased libido (which will return after discontinuing use).

I don't see any drug interactions.

Antiulcer Drugs:

Histamine₂ Blockers:

ranitidine (Zantac) prototype drug p. 701

More potent than cimetidine (Tagamet) with fewer side effects and drug interactions. It's the most frequently prescribed H₂ blocker.

Contraindicated: severe renal or liver disease

Drug interactions: Separate antacids by 1h. Decreases the absorption of ketoconazole. Increases effects of oral anticoagulants. Toxic with metoprolol.

Used: to treat peptic ulcers, GERD and stress ulcers

Side Effects: headache, confusion, constipation or diarrhea, rash, blurred vision. Hepatotoxicity is an adv. rxn.

Other: Avoid smoking; take B12 supplement to avoid deficiency due to drug therapy. Large doses are effective for controlling Zollinger-Ellison syndrome, whereas cimetidine (Tagamet) is not effective in controlling the symptoms of this disorder.

Zollinger-Ellison Syndrome

one or more tumors that form in the pancreas or upper part of the small intestine and sectete large amounts of the hormone gastrin which increases acid production in the stomach.

Antiulcer Drugs:

Proton Pump Inhibitors (PPIs)

Examples and how they work?

• omeprazole (Prilosec)
• lansoprazole (Prevacid)
• rabeprazole (Aciphex)
• pantoprazole (Protonix)
• esomeprazole (Nexium)
  dexlansoprazole (Dexilant)

They work by suppressing gastric acid secretion. All PPIs in large doses can be combined with antibiotic to treat H. Pylori

Antiulcer Drugs:

Proton Pump Inhibitors (PPIs):

Drug interactions

Can enhance the action of digoxin, oral anticoagulants, certain benzos, and phenytoin, because they interfere with liver metabolism of these drugs.

(this includes the interactions she wants us to know for lansoprazole (Prevacid))

Antiulcer Drugs:

Proton Pump Inhibitors (PPIs)

esomeprazole (Nexium) prototype drug p. 703

The duration of action is 24h. It has the highest success in healing erosive GERD. Take BEFORE meals.

Drug interactions: May interfere with absorption of ampicillin, ketoconazole, and digoxin

Caution should be used in patients with hepatic disease

Side effects: headache, blurred vision, dry mouth, diarrhea, constipation rash

May want to offer nonpharm ways to handle GERD to pt, and tell pt. that it decreases stomach acid secretion.

Antiulcer Drugs:

Pepsin Inhibitor (Mucosal Protective Drug)

Does not neutralize acid or acid secretion, it is nonabsorbable. It combines with protein to form a viscous substance that covers the ulcer and protects it from acid and pepsin. It is taken 4 times a day (short duration of action) before meals and at bedtime. Can cause constipation.

A patient is suspected to have peptic ulcer disease from H. pylori. The patient asks the nurse what kind of testing will be done to determine the cause of the peptic ulcer. The nurse will inform the patient that

A.blood cultures will need to be drawn.

B.a biopsy of the stomach will be done.

C.a breath test will be performed.

D.computerized scanning will identify if H. pylori is present.

Answer: C

Rationale: In the past, endoscopy and a biopsy of the gastric antrum were needed to check for H. pylori. Currently a noninvasive breath test, the Meretek UBT, can detect H. pylori. This test consists of drinking a liquid containing 13C urea and breathing into a container. If H. pylori is present, the bacterial urease hydrolyzes the urea, releasing 13CO2, which is detected by a spectrometer. This test is 90% to 95% effective for detecting H. pylori. In addition, a serology test may be performed to check for antibodies to H. pylori.

The patient tells the nurse that he has been treating his stomach pain with a lot of calcium carbonate. It is most important for the nurse to assess the patient for

A.Burnett’s syndrome.

B.hypernatremia.

C.metabolic alkalosis.

D.acid rebound

Answer: A

Rationale: Hypercalcemia and Burnett’s syndrome, formerly called milk-alkali syndrome, can result from excessive use of calcium carbonate. Excess sodium bicarbonate use may cause hypernatremia and water retention, metabolic alkalosis caused by excess bicarbonate, and acid rebound.

The patient is ordered cimetidine (Tagamet). It is most important for the nurse to teach the patient about what dietary needs?

A.Avoid use of salt substitutes.

B.Eat foods rich in vitamin B12.

C.Eat a high-protein diet.

D.Avoid citrus foods.

Answer: B

Rationale: Teach patient to eat foods rich in vitamin B12 to avoid deficiency as a result of drug therapy.

Which medications are most likely to be included in a dual drug therapy program for peptic ulcer disease from H. pylori?

A.Omeprazole and clarithromycin

B.Tetracycline and metronidazole

C.Ranitidine and amoxicillin

D.Ciprofloxacin and sucralfate

Answer: A

Rationale: Omeprazole and clarithromycin are commonly included in a dual drug therapy program for peptic ulcer disease from H. pylori.

The nurse has taught a patient about sucralfate (Carafate). Which statement indicates that the patient requires further teaching?

A.“I need to increase my fluid intake.”

B.“I need to report pain or vomiting of blood.”

C.“I need to take Carafate 30 minutes after meals.”

D.“I need to take Maalox 30 minutes before or after Carafate.”

Answer: C

Rationale: Carafate should be taken 30 minutes before meals, not after. Fluids should be encouraged to prevent constipation and dry mouth. The patient should report any pain or vomiting of blood. Antacids should be taken either 30 minutes before or 30 minutes after sucralfate (Carafate).

A patient with peptic ulcer disease is noted to have a positive breath test for H. pylori. The nurse would anticipate treating the patient with

A.antacids and narcotics.

B.pepsin inhibitors and antiemetics.

C.proton pump inhibitors and antibiotics.

D.emetic agents and tranquilizers.

Answer: C

Rationale: A common treatment protocol for H. pylori is triple antibiotic therapy and a proton pump inhibitor.

An older adult patient reports taking aluminum hydroxide (Amphojel) on a daily basis to relieve symptoms of GERD. The nurse needs to evaluate for which condition?

A.Constipation

B.Diarrhea

C.Flatulence

Abdominal pain

Answer: A

Rationale: Use of aluminum hydroxide most often causes constipation. Magnesium products can cause diarrhea.

When administering the histamine2 blocker ranitidine (Zantac), the nurse will

A.monitor laboratory results because ranitidine decreases the effect of oral anticoagulants.

B.separate ranitidine (Zantac) and antacid dosage by at least 1 hour if possible.

C.teach the patient to avoid foods rich in vitamin B12.

D.expect a reduction in the patient’s pain to occur after 5 days of therapy.

Answer: B

Rationale: Antacids can be given 1 hour before or after ranitidine (Zantac) as part of the antiulcer drug regimen. Ranitidine (Zantac) can increase the effect of oral anticoagulants. Patients on ranitidine (Zantac) should eat a diet rich in vitamin B12 to avoid deficiency as a result of drug therapy. The patient’s abdominal pain is expected to decrease after 1 to 2 weeks of drug therapy.

A patient with a gastric ulcer is ordered sucralfate (Carafate). This medication works to

A.calm the patient to reduce acid production.

B.block the H2 receptors.

C.neutralize the gastric acids.

D.coat the gastric lining.

Answer: D

Rationale: Sucralfate (Carafate) is a mucosal protective drug. It forms a viscous substance that covers the ulcer and protects it from acid and pepsin.

A patient who complains of gastric distress from NSAIDs such as aspirin or indomethacin will most likely benefit from the administration of which medication?

A.Misoprostol (Cytotec)

B.Lansoprazole (Prevacid)

C.Magaldrate (Riopan)

D.Magnesium trisilicate (Gaviscon)

Answer: A

Rationale: Patients who complain of gastric distress from NSAIDs such as aspirin or indomethacin prescribed for long-term therapy can benefit from misoprostol.

A patient has been prescribed aluminum hydroxide (Amphojel) and has received patient teaching. Which statement by the patient indicates an understanding of the instructions?

1. “I will take aluminum hydroxide at mealtime.”
2. “I will drink 2 ounces of water after taking aluminum hydroxide.”
3. “I will take aluminum hydroxide within 30 minutes of my other medications.”
4. “I will take a laxative if I develop constipation.”

2

The patient should drink 2 ounces of water after taking aluminum hydroxide to ensure the drug reaches the stomach. Aluminum hydroxide should not be taken at mealtime as it slows gastric emptying time. Aluminum hydroxide should not be taken within 1 to 2 hours of other oral medications. The patient should contact the health care provider if constipation develops as the antacid may need to be changed; self-treatment should be avoided.

What is a priority nursing intervention when administering ranitidine (Zantac)?

1. Administer just before meals.
2. Administer right after eating.
3. Administer 1 to 2 hours after meals.
4. Administer during meals.

1

Ranitidine (Zantac) should be given just before meals to decrease food-induced acid secretion or at bedtime.

The health care provider prescribes lansoprazole (Prevacid) for a patient. Which assessment indicates to the nurse that the medication has had a therapeutic effect?

1. The patient has no diarrhea.
2. The patient has no gastric pain.
3. The patient has no esophageal pain.
4. The patient is able to eat.

3

Lansoprazole (Prevacid) is a proton pump inhibitor that is effective in suppressing gastric acid secretions. An absence of esophageal pain would be an indication that the patient does not have reflux esophagitis.

The nurse is caring for a patient who is taking sucralfate (Carafate) for treatment of a duodenal ulcer. Which assessment requires action by the nurse?

1. A sodium level 140 mEq/L
2. Absent bowel sounds, hard abdomen
3. Urinary output of 30 mL/hr
4. A calcium level 8.5 mg/dL

2

As sucralfate (Carafate) is not systemically absorbed, there are few adverse effects. Constipation is an adverse effect of sucralfate, so the absence of bowel sounds and a hard abdomen would require immediate action from the nurse. The sodium level listed is considered to be within the normal range; 30 mL/hr is a normal urinary output.

What information will the nurse include in a teaching plan for the patient who is prescribed sucralfate (Carafate)?

1. “This medication will neutralize gastric acid.”
2. “This medication will enhance gastric absorption of meals.”
3. “This medication will form a protective barrier over the gastric mucosa.”
4. “This medication will inhibit gastric acid.”

3

Sucralfate (Carafate) affects the gastric mucosa. It forms a paste-like substance in the stomach, which adheres to the gastric lining, protecting against adverse effects related to gastric acid. It also stimulates healing of any ulcerated areas of the gastric mucosa.

The patient’s health care provider prescribes rabeprazole (Aciphex) to a patient. The nurse recognizes that this drug is effective for the patient because it belongs to which drug class?

1. Antiinfective agent
2. Proton pump inhibitor
3. Antacid
4. Histamine₂ blocker

2

The drug rabeprazole (Aciphex) is classified as a proton pump inhibitor.

The health care provider has prescribed lansoprazole (Prevacid) for the patient. Within 30 minutes of receiving the first dose of the medication, the patient experiences shortness of breath and develops a rash on his skin. What does the nurse expect that the patient is experiencing?

1. Unexpected side effect of the medication
2. Toxic level of the medication
3. Allergic reaction to the medication
4. Typical side effect of the medication

3

The patient’s symptoms are indicative of an allergic reaction to the medication.

The patient has been prescribed a treatment regimen that includes nizatidine (Axid). Which statement by the patient indicates a therapeutic outcome?

1. “I don’t have any more stomach pain.”
2. “My constipation has been relieved.”
3. “I don’t have such frequent headaches.”
4. “My anxiety has been under control.”

1

Nizatidine (Axid) is used to treat stomach ulcers and to prevent their recurrence.

Which statement demonstrates to the nurse that the patient understands instructions regarding the use of histamine₂-receptor antagonists?

1. “Since I am taking this medication, it is all right for me to eat spicy foods.”
2. “Smoking decreases the effects of the medication, so I should try a cessation program.”
3. “I should take this medication 1 hour after each meal to decrease gastric acidity.”
4. “I should decrease bulk and fluids in my diet to prevent diarrhea.”

2

Patients taking histamine₂-receptor blocking agents should avoid spicy foods, extremes in temperatures, alcohol, and smoking. They should also increase bulk and fluids in their diets to prevent constipation. The medications should be taken with meals, not after meals.

The nurse is caring for a patient who is experiencing gastric distress from the long-term use of aspirin for treatment of arthritis. Which intervention does the nurse anticipate that the provider may order?

1. Stop all aspirin therapy.
2. Administer misoprostol (Cytotec).
3. Instruct the patient to take the aspirin with milk.
4. Instruct the patient to take the aspirin on an empty stomach.

2

Misoprostol (Cytotec) is indicated for the prevention of NSAID-induced ulcer. It may be taken during NSAID therapy, including with aspirin. The patient may not be able to be completely taken off of all aspirin products; there is no evidence to support the need to take the aspirin with milk. Certain drugs like NSAIDs, which include aspirin, should be taken with food.