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Could lansoprazole be used here instead?
17054
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yeah I had the same question, just cause hes allergic to one PPI does that mean hes off all of them? like is this like amoxicillin no penicillin rule?
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DNA Tachycardia
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That's what I also put
39742
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Just Another Med Student
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Lymph Juice
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all H2 receptor are on hold, no?

17390
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No, only ranitidine is discontinued due to impurities in the product. Others like famotidine are still available
40510
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Gastro Complement
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JAK Botox
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Why is ranitidine wrong? its in the bnf as an option 
60662
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says do not prescribe lower down but just remove it from the bnf innit!
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Ortho bro
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Nightshift Bradykinin
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where on the bnf can you find a list of H2 antagonists?
61547
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go to 'clinical knowledge summaries' (one of the tabs), type dyspepsia -> functional dyspepsia -> H2 receptor antagonists
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Myotonia Loose
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We aren't allowed to use CKS in the PSA :/

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Miabetes Dellitus
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Kawasaki Pudendal
Concept
Chapter
# Summary

Gastro-oesophageal reflux disease (GORD) is characterised by the reflux of gastric contents into the oesophagus due to a defective lower oesophageal sphincter. Key signs and symptoms include dyspepsia, sensation of acid regurgitation, and potentially more atypical symptoms such as epigastric pain and laryngitis. Alarm symptoms include weight loss and persistent vomiting. Key investigations include a trial of proton pump inhibitor therapy and oesophagogastroduodenoscopy (OGD) if certain symptoms are present. Management strategies include lifestyle interventions, proton pump inhibitor therapy, and in refractory cases, anti-reflux surgery.

# Definition

Gastro-oesophageal reflux disease (GORD) is a clinical diagnosis based on the presence of typical symptoms (dyspepsia, ""heartburn"" or ""acid reflux"") resulting from the reflux of gastric contents into the oesophagus caused by a defective lower oesophageal sphincter.

# Epidemiology

In the UK, about 10% of adults experience symptoms of GORD daily, with a higher prevalence observed in individuals over 50 years of age.

# Aetiology

GORD is caused by a defective lower oesophageal sphincter, which enables the reflux of gastric contents into the oesophagus.

Risk factors contributing to the development of GORD include obesity, alcohol use, smoking, and intake of specific foods (e.g. coffee, citrus foods, spicy foods, fat).


# Signs and symptoms

Typical symptoms:

- Dyspepsia (""heartburn"")
- Sensation of acid regurgitation 

Atypical symptoms:

- Epigastric or chest pain
- Nausea
- Bloating
- Belching
- Globus
- Laryngitis
- Tooth erosion

Alarm symptoms:

- Weight loss
- Anaemia
- Dysphagia
- Haematemesis
- Melaena
- Persistent vomiting

# Differential Diagnosis

Conditions that may present similarly and should be considered in the differential diagnosis include:

- Gastric ulcers: These may present with epigastric pain, nausea, vomiting, and weight loss.
- Oesophageal cancer: This may present with dysphagia, weight loss, and potentially haematemesis.
- Functional dyspepsia: This condition may present with similar gastrointestinal symptoms without a clear organic cause.
- Hiatus hernia: Often coexists with GORD but can cause pain without significant reflux.


# Investigations

-  Urea (13C) breath test, Stool Helicobacter Antigen Test (SAT), or laboratory-based serology  **if** symptoms suggestive of H.pylori infection.
- Oesophagogastroduodenoscopy (OGD) if alarm features or atypical, persistent or relapsing symptoms are present.
- Oesophageal manometry

**Referral criteria for urgent (within 2 weeks) OGD to investigate for oesophageal and gastric cancer:**

- Aged 55 years and over with weight loss + dyspepsia/reflux

Referral criteria for non-urgent OGD:

Aged 55 years and over plus

- Treatment-resistant dyspepsia
 
OR

- Raised platelet count + dyspepsia/reflux
- Nausea/vomiting + dyspepsia/reflux

# Management

- Lifestyle interventions - weight loss, dietary changes, elevation of the head of the bed at night, avoidance of late-night eating.
- Proton pump inhibitor therapy. For patients <40 years old who present with typical symptoms and no red flags, commence treatment with a standard-dose PPI for 4 weeks in combination with lifestyle changes.
	- If the patient meets criteria for urgent OGD, they should only be commenced on PPI therapy after this has been done
- Antacids for symptomatic relief.
- Anti-reflux surgery for refractory cases.
- Treatment for H.pylori infection if confirmed (PPI + antibiotics), with retesting using the urea breath test
	-  It should not be performed within 2 weeks of treatment with a proton pump inhibitor or within 4 weeks of antibacterial treatment, as this can lead to false negatives.

# Complications

Potential complications of GORD include:

- Oesophageal ulcer
- Oesophageal stricture
- Barrett's oesophagus
- Adenocarcinoma of the oesophagus

# NICE Guidelines 

- [NICE: Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management](https://www.nice.org.uk/guidance/cg184)

# References

- [BMJ Best Practice: Gastro-oesophageal reflux disease](https://bestpractice.bmj.com/topics/en-gb/82)
- [European Association of Endoscopic Surgery: Recommendations for the management of gastroesophageal reflux disease](https://link.springer.com/article/10.1007/s00464-014-3431-z)
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# Drug choice feedback

This gentleman has benign gastric ulceration. Whilst a proton-pump inhibitor is first line, his allergy is a contra-indication. Hence, H2-antagonists have to be used. The options licensed in the UK are as above. Antacids only provide short-term symptomatic relief but do not definitively treat benign gastric ulceration.

# Dose/Route/Frequency/Duration feedback

Each medication has its own optimal dose. All are orally taken and have varying dosing frequencies.
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300 mg
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nizatidine 300 mg capsules
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4 weeks
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daily (OD)
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oral (PO)
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PrescribeAnswerData
400 mg
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cimetidine 400 mg tablets
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4 weeks
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twice daily (BD)
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oral (PO)
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PrescribeAnswerData
40 mg
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famotidine 40 mg tablets
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4 weeks
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nightly
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oral (PO)
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PrescribeAnswerData
2 g
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sucralfate 1 g tablets
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4 weeks
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twice daily (BD)
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oral (PO)
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1 g
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sucralfate 1 g tablets
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4 weeks
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four times daily (QDS)
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oral (PO)
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PrescribeAnswerData
800 mg
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cimetidine 800 mg tablets
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4 weeks
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once only (STAT)
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oral (PO)
Case Presentation: A 57-year-old gentleman presents to his GP with dyspepsia. He does not report any weight loss, no vomiting, no changes to appetite.


## PH

Obesity

## DH

NIL (Allergy to Omeprazole)

## FHx

No upper gastrointestinal cancer

## On examination

Alert and oriented. Mild epigastric tenderness, otherwise abdomen soft and non-tender, no masses palpated.

Temperature 36.8°C, HR 70, RR 13, BP 139/81, O<sub>2</sub> 98% RA, GCS 15, Weight 86kg

## Investigations

FBC: Hb 152, WCC 6.2, Plt 283
Urgent OGD performed: "Benign gastric ulceration noted, no oesophagitis, no masses seen."

Stool antigen test for _H. pylori_: negative

# Prescribing Request

Write a prescription for one drug that is most appropriate for treating his condition.