Why nitroglycerin relieve GERD symptoms?

[seasurfer]

I apologize if I am not posting in the right place. I am curious to know why nitroglycerin can relieve the symptoms of GERD? I have looking all over the place and couldn't find the answer. Thanks.

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[Frugal Traveler]

NO's end-game is cGMP.

I believe that rather than GERD... it is used for diffuse esophageal spasm. CCBs are also used for this purpose.

For GERD, you would give a PPI typically as the pathophysiology involves a decreased LES pressure and subsequent reflux of acid. NO (as well as CCB) may cause lowered LES pressure and subsequently may not be a great idea for GERD patients.

 

[seasurfer]

NO's end-game is cGMP.

I believe that rather than GERD... it is used for diffuse esophageal spasm. CCBs are also used for this purpose.

For GERD, you would give a PPI typically as the pathophysiology involves a decreased LES pressure and subsequent reflux of acid. NO (as well as CCB) may cause lowered LES pressure and subsequently may not be a great idea for GERD patients.

You are right to say that. But many patients who took NTG during GERD tend to report a relieve of symptoms, it is also one of the points mentioned in a Step 3 book. That is why I would like to know the physiology behind it.

Step Up Step 3 Page 14, under quick hint, it mentioned that symptoms of GERD may be relieved by NTG, but never explain why.

 

[Frugal Traveler]

You are right to say that. But many patients who took NTG during GERD tend to report a relieve of symptoms, it is also one of the points mentioned in a Step 3 book. That is why I would like to know the physiology behind it.

Step Up Step 3 Page 14, under quick hint, it mentioned that symptoms of GERD may be relieved by NTG, but never explain why.

I took a look in Harrison's, and the book states:
" A sustained hypotension of the LES may be due to muscle weakness that is often without apparent cause. Secondary causes of sustained LES incompetence include scleroderma-like diseases, myopathy associated with chronic intestinal pseudo-obstruction, pregnancy, smoking, anticholinergic drugs, smooth-muscle relaxants (

-adrenergic agents, aminophylline, nitrates, calcium channel blockers, and phosphodiesterase inhibitors), surgical damage to the LES, and esophagitis."


It may be an error in the book. Anyhow, the NBME tends to test GERD as a differential in asthma (like coughing after meals in an asthmatic). If they ask a question about GERD, and they say treat it with nitrates... I would think it is the wrong answer! Angina... yes... I could understand that (decrease preload).


Perhaps it is an error in the book as I would suspect they meant DES.

 

[dragonfly99]

I agree that sounds like an error.
I agree w/Frugal Traveler.
Treatment for GERD would be antacids like Tums, etc., an H2 blocker or a proton pump inhibitor.

Esophageal spasms may respond to calcium channel blockers or nitrates. I have had success giving calcium channel blockers to a couple of patients, particularly if they had HTN as well (killing 2 birds w/one stone).

 

[seasurfer]

I agree that sounds like an error.
I agree w/Frugal Traveler.
Treatment for GERD would be antacids like Tums, etc., an H2 blocker or a proton pump inhibitor.

Esophageal spasms may respond to calcium channel blockers or nitrates. I have had success giving calcium channel blockers to a couple of patients, particularly if they had HTN as well (killing 2 birds w/one stone).

Thanks again for the reply. I think the book is trying to point out that GERD is one of the differential of Angina Pectoris. As both of these will see relieve of symptoms after taking NTG. But what I really don't understand is how NTG relieve GERD?

The book is not suggesting using NTG to treat GERD, but mention that if NTG were taken during GERD it may relieve the symptoms.

 

[PirateHotel]

I also think it's an error in the book you are using.. The relieving effect of NTG on angina and esophageal spasm is classic for board exams -- for extra points NTG takes a bit longer to relieve spasm.

GERD is relieved by antacids.

 

[Frugal Traveler]

Lippincott books tend to have a ton of errors... Elsevier is typically the way to go (except Goljan had a ton of errata!).

Note: FT has no interest or investments in either company.

 

[Acherona]

Nitro seems to make anyone everyone feel better regardless of the etiology of their pain. I've seen ppl with MSK pain, gerd, pleuritic pain, all say the pain was relieved with nitro. Correct me if I'm wrong but I don't think nitro has a morbidity or mortality benefit in MI so the mechanism for relief in that instance may also be different than what we think i.e. coronary vasodilation.

 

[Frugal Traveler]

Correct me if I'm wrong but I don't think nitro has a morbidity or mortality benefit in MI so the mechanism for relief in that instance may also be different than what we think i.e. coronary vasodilation.

I don't recall anything about a benefit for nitro on morbidity/mortality.

The mechanism of relief involves a decrease in preload as nitroglycerin acts on the venous capacitance veins. Remember that lesions in coronary arteries that are flow-limiting will cause the artery to be already maximally dilated... this is exploited in the "coronary steal" phenomenon during some forms of cardiac stress testing but not for the acute treatment of MI.

For complex regional pain syndromes, fibromyalgia, and those other "favorites" in IM/FM outpatient clinic, I think it is hard to determine if nitroglycerin actually helps with MSK pain or not. It has been documented in IBS studies (another one of those "favorites") that trials need to have a length of 3 months or so at minimum to sort out a placebo effect (which nitroglycerin could easily have for these "favorites"... but obviously it has a defined and useful mechanism for stable angina). After ruling out organic causes for the "favorites," a "graded exercise program" usually does the trick... these patients are already de-conditioned... and its hard to complain if you are walking outside and it's sunny

As stated above, both nitrates and CCBs can potentially exacerbate GERD given their actions on the LES. It would be inappropriate to hand out nitrates like candy because you are going to get sued at sometime with these elderly people and their Viagra in the nursing homes! Talking about sowing some oats as old as the Quaker brand.

 

[tarlovcyst]

Nitroglycerin helps because the chest pain is really angina that presents as GERD-like symptoms. As of my knowledge, there is zero literature that supports the beneficial effects of nitroglycerin in GERD.

 

[elwademd]

why? i don't know.

the take home point should be that all pain relieved by nitroglycerin is not chest pain... and the flipside is that not all chest pain is relieved by nitroglycerin.

in other words, when the er calls you to admit a "chest pain relieved by nitro" keep your differential open. don't just buy into the diagnosis because the er doc did. it certainly could be chest pain... but it could be something else, such as gerd.