25 - PUD / SRMD Flashcards
First-Line Regimens for
Treatment of H.Pylori
GERD
CLARITHROMYCIN TRIPLE
PPI + Clarythromycin + Amoxicillin
14 days
- *BSMUTH QUADRUPLE**
- *PPI + Tetracycline + Metronidazole + Bismuth Subcitrate**
10-14 days
Clarithromycin Triple
First Line Treatment for H. Pylori
PUD
14 Day treatment - PCA
- *PPI BID**
- *standard OR double dose**
- *Clarithromycin**
- *500mg BID**
- *Amoxicillin**
- *1000 mg BID**
- IF PCN ALLERGY –>*
- *Metronidazole 500mg TID** instead
Bismuth Quadruple
First Line Treatment for H. Pylori
PUD
Helidac = pack w/o PPI
Pylera = pack with PPI
10 - 14 Day Treatment - PTMB
PPI
STANDARD dose = BID
- *Tetracycline**
- *500 mg QID**
- *Metronidazole**
- *250 mg QID** or 500mg TID/QID
- *Bismuth Subcitrate** or Subalicylate
- *120-300mg** or 300mg QID
Mucosal Protectants
for PUD
Sucralfate
1g QID or 2g BID
ALUMINUM may accuminate in RENAL FAILURE
- *Misoprostol**
- *100-200mcg QID**
- Contraindicated in PREGNANCY*
GI RISKS
PUD: NSAID-Induced
Low = 0 // moderate = 1-2 // high > 2 Risk factors
GI Risks:
h/o of PUD (+ complications)
Age > 60 years
Concomitant Medications
anticoags / corticosteroids / other NSAIDS (includes baby aspirin)
contributing factors:
smoking / CVD / H. Pylori
CV Risks
for PUD: NSAID-Induced
- *High Risk**
- *requirement for Low-dose Aspirin**
such as individuals with:
prior CV event
diabetes / HT
hyperlipidemia / obesity
Table for treating a patient with
NSAIDs
based on CV / GI Risk
Risk Factors for
PUD BLEEDING
Higher risk w/ poor prognosis:
> 60 y/o
Comorbid Conditions
HIGH Transfusion Requirements
ongoing blood loss
hypoVolemic Shock
prolonged PTT / increased INR
erratic mental status
may need aggressive intervention or ICU stay
Comparison Chart of DIFFERENT PUD’s
SRMD / NSAID / H. Pylori
RISK FACTORS
for SRMB PUD
Mechanical Ventilation > 48 hours
Coagulopathy
Platelets <50K // INR >1.5 // PTT> 2.5 normal
Liver Failure / Sepsis / GIB History
Major Surgery / ICU >7 days
HIGH-DOSE Corticosteroids (>250mg/d HC)
Severe Burns (>35% BSA)
traumatic Spinal / Head Injury
PROPHYLAXIS
for SRMB PUD
FLUID replacement -> restore mucosal blood flow
Intragastric pH > 4 = for mucosal protection
- *Pharmacotherapy**
- *anti-secratory** or Mucosal protectant
H2RA > PPI
by IV or PO route, make sure they can take PO first
only use PPI if
renal dysfunction develops thrombocytopenia or mental status changes while on H2Ra
GIB Treatment
PUD
correct fluid loss
Endoscopic intervention
IV PPI
LD is equivalent to 80mg omeprazole
then do 8mg/h continuously for 72 hours
- WHY NOT H2RA?*
- does NOT achieve* pH of 6
- does NOT PREVENT rebleeding / tachyphylaxis*
Signs & Symptoms of
PUD
Dyspepsia / Indigestion
Post-prandial Bleeding (bleeding after meals)
Abdominal fullness/bloating
Anorexia / weight loss / early satiety
N/V + Cramping/pain
PUD ALARM Symptoms
When to REFER TO MD
ANEMIA
- *Hematemesis**
- vomiting of blood*
Melena / Heme +pos+ stool
Anorexia / Weight Loss
SEVERE Upper Abdominal Pain
Causes / Risks of PUD
NSAID USE = #1
H. PYLORI = #2
50% of population has H.pylori, 10-15% develop PUD
SRMD / Stress Ulcer
Zollinger-Ellison Syndrome = ZES
gastrin-secreting tumor or hyperplasia of the islet cells in the pancreas resulting in recurrent peptic ulcers
Cigarette Smoking / Alcohol / Diet
Idiopathic / Radiation / Genetic Subtypes
MEDICATIONS = Steroids / bisphosphate / chemo / SSRI
Complications of PUD
Active UPPER Gi Bleeding
PUD = MOST common cause of acute GI bleed
Perforation
Gastric Outlet Obstruction
scarring / edema
can require Surgery or cause Death
Timing of PUD Symptoms
GU = Gastric
occurs SOON after a meal
DU = Duodnem
occurs usually 2-5 hours after a meal or during the night
Ulcerogenic / Hostile Factors
vs Protective / Healing Factors
in PUD
Gastric Acid / H. Pylori / Pepsin
NSAIDS
vs
- *Bicarb / Prostaglandins / Mucus Production**
- *Blood Flow** to Mucosa
Treatment Chart of
PUD
dyspepsia (indigestion) ->
Alarm Symptoms or >55 y/o
Yes -> EGD (esophagogastroduodenoscopy)
NO:
detect / treat H. Pylori
Advice DC of NSAIDS / Smoking / Alcohol / Drug
Administer antisecretory therapy = PPI f4weeks
H. Pylori
Gram negative bacteria, sits between mucus/gastric epithelium
Produces UREASE –> hydrolyzes urea in gastric juice
–> Ammonia & CO2 –> buffer effect from gastric acid
NOT appropriate to test ALL PATIENTS
transmitted by:
oral/fecal/gastro
contaminated food/water
infected patients within household
Non-Endoscopic
Tests for H. Pylori
Test whether ENDOSCOPY is Required
or Strengths / Weaknesses of each test
- *Serologic Test**
- easy, but positive might reflect a PAST INFECTION*
Urea Breath Test
useful before and after treatment
false negatives in presence of PPIs / other antibiotics
Fecal Antigen Test
useful before and after treatment
false negatives with PPI/antibiotics /bismuth
Key Questions for
H.Pylori PUD Treatment
is there a PENICILLIN ALLERGY? PCN
use metronidazole 500mg TID –> instead of AMOX
in Clarithromycin Triple Therapy
Is there a PREVIOUS MACROLIDE EXPOSURE
MCL, for anyreason?
What to do AFTER
H.Pylori Treatment for PUD
Check eradication using:
UBT (urease breath test)
FAT ( Fecal Antigen Test)
Biopsy based test (endoscopic)
- *> 4 weeks** after :
- *completing AB therapy** & withholding PPI therapy for 1-2 weeks
After H. Pylori PUD Treatment
if a SMALL <1cm Uncomplicated Ulcer?
sufficient with
Triple Regimen Alone + 4 Weeks PPI
follow up may NOT be needed
After H. Pylori PUD Treatment
if COMPLICATED ULCERS
REPEAT Endoscopy w/ BIOPSY
after therapy completion to confirm healing
CONTINUE PPI THERAPY
antisecretory = PPI or H2RA
What should a patient take for
NSAID-INDUCED PUD
if MODERATE (1-2 risk factors) GI RISK
or if also has HIGH CV RISK = needs a baby aspirin
NSAID needs to be taken with:
PPI** or **MISOPROSTOL
100-200 mcg QID
PROPHYLAXIS / PREVENTION
of NSAID -Induced PUD
Only give to HIGH RISK PATIENTS
>2 GI Risk factors / CV Risk = baby aspirin need
- *MISOPROSTOL** = Cytotec
- *200 mcg QID**
- not for PREGNANCY, also diarrhea / ab pain*
PPIs are also an acceptable alternative
H2RA / Sucralfate are NOT recommended for prophylaxis
Antacids / EC-ASA do NOT reduce risk of complications
TREATMENT
of NSAID-Induced PUD
Discontinue the NSAID
if possible –> replace with other AGENT
(COX-2 inhibitor in non-CV patients)
Or Reduce NSAID DOSE** & **Add Ulcer Prevention strategies
low dose ASA should be held for 7-10 days
PPI = Agent of Choice
to heal NSAID-Induced ulcers
also when NSAID needs to be continued, or if H.Pylori is involved
PUD-Related GIB
Signs / Symptoms
Hematemesis / Hematochezia
blood in VOMIT / STOOL
Melena
dark / sticky feces
Intravascular Volume Loss
HR > 100
hypoTension SBP < 100 / postural changes
Mucous mebranes
Treatment considerations for PUD
H2RAs
Equipotent, generally do NOT want to use
RENALLY CLEARED
Tachyphylaxis = TOLERANCE to antisecretory effects
Cigarette smokers may need HIGHER dose / Longer treatment
DO NOT USE FOR GI BLEED
does NOT achieve pH 6
does NOT prevent re-bleeding
Sucralfate
PUD Treatment Considerations
NOT often used for PUD
multiple doses / day
Large tabs
ADRs - Constipation / Seizures
need to seperate from interacting drugs
NSAIDs & ASA
Effects on PUD
NON-SELECTIVE
INHIBIT BOTH COX-1 & COX-2
_COX1
DIRECT IRRITANTS_
of the gastric epithelium
COX 2
Inhibition of the endogenous
Prostaglandin Synthesis
COX-2 Inhibitors
Effects on PUD
COX-2
Inducible by Cytokines + GF’s
- *Inhibition of the endogenous**
- *Prostaglandin Synthesis**
COX = rate limitign step in:
Arachidonic acid –> Prostaglandins
Pathophysiology of SRMD
Critical Illness
vasoconstriction / reduced cardiac output / Inflammatory release
v v v v
Splanchnic hypoPerfusion
reduced HCO3 secretion / mucosal blood flow
dereased GI motility / acid back
v v v v
ACUTE STRESS ULCER
Salvage Therapy for
H. Pylori INFECTION - PUD
mainly based on:
WHAT THEY FIRST TOOK
Clarithromycin 3x Therapy /// Bismuth 4x Therapy
&
WHAT THEY ARE ALLERGIC TO
Quinolone /// PCN Allergy
