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GERD, GASTRITIS, and the GI Cocktail: A Deep Dive into Acid Reflux

Emergency (ER) Gastro (GI) Medications & Therapies
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I’ve always said nurses are like bartenders… they just pass out GI cocktails instead of regular ones!

This article dives into the very common and annoying issue of acid reflux, GERD, and gastritis. We will also dive into solutions to help your patients along the way. You may find yourself needing a GI cocktail after the nightshift potluck anyway 😅.

What is Gastroesophageal Reflux Disease (GERD) & Gastritis?

Acid reflux can be a very painful and annoying condition. If left unchecked, acid reflux can cause serious damage to the stomach, leading to heartburn, ulcers, GI bleeds, and and even certain types of cancers.

Acid reflux is a general term for when acid comes up into the esophagus from the stomach. We have something called the Lower Esophageal sphincter (LES) which is supposed to close tightly and prevent this from happening. Sometimes this malfunctions.The stomch with acid and reflux present

GERD stands for Gastroesophageal Reflux Disease. This is basically the medical term for when heartburn and acid reflux is bad enough to cause significant symptoms. Acid flows back up the esophagus, which can cause a lot of irritation. The stomach is lined to handle the acid contents of the stomach, but the esophagus is not!

Gastritis stands for inflammation of the stomach. This can be sudden or acute, but the actual stomach lining is irritated and sometimes erodes into ulcers.

While GERD focuses more on esophageal irritation, gastritis focuses on inflammation to the lining of the stomach.

What is a GI cocktail and how does it help with Acid Reflux?

A GI cocktail is a mixture of 3 different types of medications that help with pain related to GERD and gastritis. These 3 different types of medications include:

A bottle of generic acid reducers

1. Antacid

Antacids help neutralize stomach acid, providing relief from the burning sensation aka heartburn that is often associated with conditions like GERD. Common antacids include Mylanta or Maalox.

A small container of viscous lidocaine 2%

2. Anesthetic

Lidocaine or other similar agents can be used to numb up the esophagus and stomach, providing relief from pain and discomfort.

Hyoscyamine syringe as part of a GI cocktail given for GERD or gastritis

3. Antispasmodic

This component can reduce muscle spasms in the stomach, helping to relieve symptoms like stomach cramps. Donnatal is a common antispasmodic used as well.

When combined, these medications work together to provide rapid relief from stomach pain (or chest pain if its GI-related). The GI cocktail is especially useful in ER and urgent care settings, where patients present with severe symptoms.

Causes of Acid Reflux, GERD, & Gastritis

Both GERD and gastritis have a range of causes. Understanding these can help in better diagnosis, management, and patient education. Here’s a deeper dive into the primary causes of each condition:

The stomch with acid and reflux present

Lower Esophageal Sphincter (LES) Dysfunction

The LES is a ring of muscle that opens to let food into the stomach and closes to keep it there. If it weakens or relaxes abnormally, stomach acid can flow back into the esophagus, causing gastroesophageal reflux disease GERD. Factors like obesity, smoking, and certain medications can contribute to this dysfunction.

H Pylori bacteria, which can lead to gastritis and peptic ulcers

H. Pylori Infection

Helicobacter pylori – or H. Pylori for short, is a bacteria that is commonly found in the stomach. Over time, it can cause inflammation, ulcers, and even increase the risk of stomach cancer. 

A box of NSAIDs which can trigger gastritis or peptic ulcers

NSAID use

Nonsteroidal anti inflammatory drugs (NSAIDs) like aspirin, ibuprofen, and naproxen, are over the counter medications that are used for pain and inflammation. These can also all reduce prostaglandin which helps protect the stomach’s inner lining. Over time, this can lead to gastritis and other stomach complications.

Hiatal hernia which can cause gastritis or GERD

Hiatal Hernia

A hiatal hernia occurs when the upper part of the stomach bulges through the diaphragm into the chest cavity. It can weaken the LES and promote acid reflux, leading to GERD.

A burger and fries which can lead to GERD or gastritis

Poor Diet

Certain foods we consume and how we eat them can contribute to heartburn, GERD, and gastritis.

  • Spicy and Acidic Foods
  • Fatty Foods
  • Caffeinated and Carbonated Beverages
  • Eating Large Meals
  • Alcohol and Chocolate

Alcohol whiskey bottle and glass with ice

Excessive Alcohol consumption

Alcohol can irritate and erode the stomach lining, leading to chronic inflammation. Chronic, heavy drinking is a common cause of gastritis.

A person who is stressed

Stress

Stress can also lead to stomach issues. This is usually due to major surgery, injury, burns, or severe infections can lead to acute gastritis. This is from increased stomach acid as your body’s response to the stress. 

A cigarette with a red X

Tobacco

Smoking or consuming tobacco products can weaken the LES and irritate the stomach. Both active smoking and exposure to secondhand smoke can be problematic and lead to health problems. 

Nursing Assessment of GERD & Gastritis

Symptoms

Both GERD and Gastritis can have similar signs and symptoms, with GERD having more common symptoms and gastritis having more severe symptoms. 

A stomach on fire, indicating heart burn

Heartburn

Often described by patients as a burning sensation in the chest, heartburn and acid indigestion is the hallmark symptom of GERD. This common symptom and burning feeling is felt just behind the breastbone and might also spread up to the neck or throat.

Female Heart Attacks

Remember that women can sometimes have very vague symptoms of heart attacks, and they may just experience heartburn or indigestion. Ruling out cardiac causes should always be suspected, depending on their medical history and health problems.

    A stomach producing gas

    Belching & Bloating

    Excessive belching can be a symptom of gastritis. Along with it, bloating or a feeling of fullness in the abdomen is common – especially if the patient has a hiatal hernia.

    The stomch with acid and reflux present

    Regurgitation

    This symptom is the sensation of stomach contents or acid flowing back into the throat or mouth. It often leaves a sour or bitter taste.

    Male abdomen with epigastic pain

    Epigastric Pain

    Particularly in gastritis, patients might experience pain or discomfort in the upper abdomen. The pain can be sharp, burning, or gnawing. Patients can even feel chest pain from stomach pain as well (this is actually a common cause of chest pain that brings patients to the emergency room thinking they’re having a heart attack!). 

    Nausea or Vomiting

    Gastritis can lead to feelings of nausea or even vomiting. Sometimes, the vomit may appear bloody or like coffee grounds in the case of a GI bleed.

    An elderly gentleman having trouble swallowing

    Trouble swallowing

    Due to consistent irritation of the esophagus in chronic gastroesophageal reflux disease GERD, patients might experience trouble swallowing or painful swallowing. Their esophagus can even develop strictures which need dilated intermittently as time progresses. They may need a barium swallow as the first step in their diagnosis, and eventually an upper endoscopy. 

    A man who isn't hungry

    Loss of appetite

    Patients with gastritis and bad acid reflux might experience reduced interest in eating due to their heartburn and other symptoms above.

    Chronic cough

    Sometimes chronic GERD can cause others ymptoms such as a dry cough that is worse when lying down.

    Physical Assessment of GERD & Gastritis

    In addition to the signs and symptoms above, GERD and Gastritis can cause some obvious signs in patients during the physical exam, including:

    Dental erosion

    Dental erosion

    Chronic acid reflux and GERD can lead to dental erosions due to frequent reflux of acid, which eats away at your teeths enamel. 

    A throat that is red and irritated

    Throat irritation

    Chronic reflux can cause erythema and irritation of the posterior pharynx, which may be visible on an oral exam.

    Male abdomen with epigastic pain

    Abdominal Tenderness

    The epigastric region tends to be tender to palpation, but generally should NOT cause any guarding or rebound. If so – these are signs of peritonitis and a potential perforation.

    Treatment of GERD & Gastritis

    Treating GERD and gastritis includes lifestyle modifications as well as a GI cocktail and other medications to help. 

    Diet and Lifestyle Changes to help acid reflux

    Lifestyle modifications which help to treat GERD and Gastritis include:

    A bowl of food, signifying dietary education for patients

    Dietary Modifications

    Lifestyle changes can make a major difference in patients with GERD and gastritis symptoms, helping their heartburn. Lifestyle changes include:

    • Consuming more frequent, smaller meals
    • Avoiding spicy, acidic, or fatty foods
    • Avoiding certain beverages like carbonated drinks can also help

    Elevated HOB at least 30 degrees

    Elevated HOB

    For GERD patients, elevating the head of the bed can prevent acid reflux, especially during sleep. Using wedges or foam inclines can be effective. 

    Alcohol whiskey bottle and glass with ice

    Limit Alcohol & Caffeine

    Both alcohol and caffeine can exacerbate symptoms. Reducing or eliminating consumption can aid in symptom relief.

    A cigarette with a red X

    Stop Smoking

    Stopping smoking can help improve LES tone, so healthcare providers should encourage patients to stop smoking (plus help many other health problems that cigarettes can cause).

    Weight Loss

    Being overweight increases the risk of GERD. Achieving and maintaining a healthy weight and making this an important lifestyle change can reduce symptoms.

    Medications (GI Cocktail anyone?)

    Medications for GERD and Gastritis involve reducing stomach acid and providing pain relief. Options include:

    A bottle of generic acid reducers

    Antacids to reduce stomach acid

    Antacids are acid neutralizers, and they can treat symptoms from persistent heartburn, acid reflux, and GERD symptoms, as well as pain from gastritis. 

    Over the counter medication options for heartburn as well as medications include: 

    • TUMS (Calcium Carbonate): 1 – 4 tablets as needed (max dose 8g/day)
    • Maalox or Mylanta (Aluminum Hydroxide & Mangesium Hydroxide) 400-800mg up to 4 times daily as needed

    Constipation

    Too much antacids can lead to a whole different GI issue – usally constipation!

    Calcium and aluminum tend to lead to constipation, and magnesium can lead to diarrhea. 

      A box of generic H2 Blockers

      H2 Blockers

      H2 blockers work by blocking the action of histamine 2 receptors. H2 produces acid in the stomach. This is often given IV in the ER setting. Common medications in this class ordered in the hospital include Pepcid:

      • PO: famotidine 20-40mg, then usually up to 20mg BID (40mg in severe cases)
      • IV: 20mg IV BID

      Kidney Disease

      Patients with kidney diseases need to be careful about dosing of their antacids as well as medications like pepcid. Healthcare providers should always consult databases like Uptodate to check with kidney dosing!

        A purple and gray pill, depicting omeprazole, which can lead to hypomagnesemia and low magnesium levels

        Proton Pump Inhibitors

        Proton Pump Inhibitors (PPIs) work by irreversibly binding to the Hydrogen/potassium pump. This blocks the final step of acid production in the stomach. This is stronger than H2 blockers, and lasts for a longer period of time. This reduction in acid allows healing of gastritis and ulcers if they are present. Healthcare Providers commonly prescribe PPIs in the hospital and outside of the hospital, including:

        • Omeprazole 20-40mg PO daily
        • Pantoprazole (Protonix) 40mg PO daily
        • Pantoprazole 40mg IV q24h

        Protonix Drip?

        Protonix drips can be started in upper GI bleeds, which is usually 80mg loading dose followed by a drip of 8mg/hr.

          A bottle of liquid medicine, a GI cocktail, which is a mixture of medication to help with Gastritis or GERD symptoms

          GI Cocktail

          As promised, the GI cocktail is very helpful in ER and urgent care settings. This mixes some of the medications above, in addition to some addition medical.

          While a GI cocktail may be a little different at each facilities, they will generally contain the following medications:

          • Liquid Antacid: Maalox or Mylanta, typically 30mL (400mg)
          • Anesthetic: Viscous lidocaine, 10-20ml of a 2% solution
          • Antispasmodic: Hyoscyamine, Donnatal, or dicyclomine (Bentyl). These decrease the motility of the stomach and can reduce cramping (so optional if no cramping present).

          How to write a prescription for a GI cocktail

          Rx:

          1. Mylanta 135mg/5mL: 30mL
          2. Hyoscyamine liquid 0.125mg/mL: 10mL
          3. Viscous lidocaine 2%: 10mL

          Sig: Mix the above components together. Administer orally. Instruct the patient to swallow the mixture.

          Disp: 1 dose

          Refills: 0

            While a lot of patients notice significant and immediate improvement from a GI cocktail, one study by the National Institute of Diabetes and Digestive and Kidney Diseases did find that a GI cocktail was no more effective than plain liquid antacid. 

            Surgical Procedures

            In severe and chronic cases when lifestyle changes are not enough, surgery can be performed to help strength the lower esophageal sphincter and prevent reflux. Most notably, this is called a Nissen fundoplication. Another option is the LINX reflux management system, which also helps reinforce the LES. Surgery to fix a hiatal hernia can also be performed.

            Complications of Gastritis & GERD

            Sometimes a GI cocktail is not going to cut it, and the patient can develop possible complications.

            Esophagitis which can cause ulcers

            Esophagitis

            Chronic exposure to stomach acid from chronic acid reflux can inflame the tissue lining of the lower esophagus and lead to esophagitis, including the surrounding esophageal muscles. This can lead to ulcers or strictures in the esophagus caused by the above. 

            Esophageal Strictures, which can occur after chronic GERD (GI cocktail can help numb up this)

            Esophageal Strictures

            Over time, untreated GERD and esophagitis can lead to the narrowing of the esophagus from scar tissue, known as strictures. This can result in difficulty swallowing and often requires dilation. 

            Dysplasia to signify Barrett's esophagus

            Barrett’s Esophagus

            In some people with long-term GERD, the cells lining the lower esophagus can become precancerous (“dysplasia”). This condition, called Barrett’s esophagus, increases the risk of esophageal cancer. Regular monitoring with endoscopy is advised for people diagnosed with this condition.

            Peptic ulcers in a stomach

            Peptic Ulcer

            Chronic inflammation can lead to the formation of ulcers, especially if the patient has H. Pylori infection. These can erode into the stomach and sometimes lead to a upper GI bleed. This usually causes significant discomfort, leading to patients seeking medical attention.

            The stomach full of blood

            Upper GI Bleed

            Erosion into blood vessels can lead to GI bleeding of the digestive system. This typically manifests as dark tarry stools, vomiting blood or coffee ground emesis, and anemia. This is a true emergency! Patients with a medical history of GI bleeds with GI symptoms should be made a priority!

            Respiratory Issues

            GERD can lead to recurrent aspiration of stomach contents into the lungs, leading to asthma symptoms like chronic cough, wheezing, or even pneumonia. 

            Summary of Acute Cholecystitis

            Causes

            Causes of Gastritis and gastroesophageal reflux disease GERD include decreased LES tone, hiatal hernia, NSAID over-use, poor diet, or an H. Pylori infection.

            Symptoms

            Include of GERD and Gastritis could be as simple as acid reflux, but often include GI upset like nausea, vomiting, epigastric pain, bloating, belching, and decreased appetite.

            Physical Assessment

            Epigastric tenderness and pretty common with gastritis, and you may find dental erosion or pharyngeal erythema from the reflux.

            Treatment

            Medical treatment includes medications to decrease the acid in the stomach, decrease stomach acid, and decrease spasms. This is where a GI cocktail can really help! Sometimes antibiotics are needed if an H. Pylori infection is present.

            And that is an overview of acid reflux, GERD, Gastritis, and why the GI cocktail is so often used in healthcare to help with these symptoms. Hopefully this gave you a good understanding of these conditions. 

            References

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