4. GERD, PUD, And Related Disorders

Question 1

What are the 3 main parts of the mucosal defense system?

Answer 1

Mucous Gel Layer

Surface epithelial cells

Subepithelial elements

Question 2

Composition of mucous gel layer

Answer 2

95% water and 5% mucin

Question 3

Which part of the mucosal defense system serves as a barrier protection?

Answer 3

Mucous gel layer

Question 4

Which part of the mucosal defense system provides cell protection and regeneration?

Answer 4

Subepithelial elements

Question 5

Which part of the mucosal defense system produces mucus and regulates pH, and produces protective heat shock proteins that prevent protein desaturation?

Answer 5

Surface epithelial cells

Question 6

Considered the “housekeeping elements”.

Answer 6

COX-1

Question 7

Exacerbating factors of GERD regardless of causative factor.

Answer 7

Abdominal obesity
Pregnancy
Gastric hypersecretory states
Delayed gastric emptying
Disruption of esophageal peristalsis
Gluttony

Question 8

Excessive reflux of gastric contents back through the LES

Answer 8

GERD

Question 9

The TWO most common GERD Sx. “Hallmark”

Answer 9

HEARTBURN and REGURGITATION

Question 10

Less common GERD Sx.

Answer 10

Dysphagia

Chest Pain

Question 11

“The great imitator”

Answer 11

Biliary colic

Question 12

Pain associated with a bad gallbladder, can present in many ways.

Answer 12

Biliary colic

Question 13

The DOMINANT clinical strategy for GERD

Answer 13

Lifestyle modifications + Empirical Tx with acid inhibitors

Question 14

How long should you try the initial tx for GERD before checking on symptomatology?

Answer 14

8-12 wks

Question 15

What are important exceptions to the GENERAL approach to tx for GERD?

Answer 15

PERSISTANT DYSPHAGIA or CHEST PAIN

Question 16

What foods reduce LES pressure?

Answer 16

Fatty foods
ETOH
Spearmint/Peppermint
Tomato-based foods
Coffee/tea

Question 17

Does reducing the acidity of gastric juice prevent reflux?

Answer 17

No, just decreases sx and allows esophagitis to heal

Question 18

The most effect GERD med

Answer 18

PPI

Question 19

What PPI do you generally start with for GERD tx?

Answer 19

Omeprazole (20 mg QDay x 8-12 weeks)

Question 20

When should pt’s take Omeprazole (PPI’s)?

Answer 20

30 min BEFORE FIRST MEAL

Question 21

What pt’s may need longer term PPI use?

Answer 21

Sx return after discontinuance of PPI

Erosive disease

Barrett’s esophagus

Question 22

What is a maintenance option for pt’s without erosive disease or Barrett’s esophagus (if effective)?

Answer 22

H2 blockers

Question 23

What is a “PPI bridge” at night?

Answer 23

H2 Blocker

Question 24

When would you do a Nissen fundoplication?

Answer 24

Intractable GERD (must have a normal esophageal function proven with manometry)

Question 25

When would you do a Toupet partial fundoplication tx?

Answer 25

Pt’s with abnormal manometry results

Question 26

GERD complications

Answer 26

Chronic esophagitis Bleeding Stricture Barrett’s Esophagus Esophageal adenocarcinoma

Question 27

What kind of cancer can Barrett’s esophagus turn into?

Answer 27

Adenocarcinoma

Question 28

Process of Barrett’s esophagus

Answer 28

Squamous cells replaced with abnormal glandular-type epithelium

Question 29

A pt. presents with anorexia and stomach discomfort...what is something you might consider?

Answer 29

Gastritis

Question 30

H. Pylori is a risk factor for the development of _______________

Answer 30

Gastric adenocarcinoma

Question 31

A pt. presents with low-grade B-cell lymphoma, what would you consider testing for?

Answer 31

H. Pylori

Question 32

What should all patients with active PUD or hx of PUD or gastric cancer be tested for?

Answer 32

H. Pylori

Question 33

What is the most ideal test for H. pylori?

Answer 33

Fecal antigen immunoassay and urea breath test?

Question 34

This test demonstrates exposure of H. Pylori, but doesn’t tell us about active infection.

Answer 34

Quantitative Serologic ELISA test

Question 35

If a pt. must stay on a PPI and you need to test for H. Pylori, what test would you use?

Answer 35

Endoscopic

Question 36

H. Pylori eradication Tx

Answer 36

Omeprazole (20mg BID) + clarithromysin 500 mg BID + amoxicillin 1 g BID x 10 days

Question 37

The most common type of PUD

Answer 37

DU

Question 38

Eating relieves this type of ulcer

Answer 38

DU

Question 39

Found in “Younger” patients (30-55)

Answer 39

DU

Question 40

What size does a break in the mucosal surface need to be to be considered an ulcer?

Answer 40

>5mm

Question 41

Eating aggravates this type of ulcer.

Answer 41

GU

Question 42

A patient complains of waking up with stomach pain at 2 am, she says she also gets a stomach ache a few hours after every meal and is “Dependent on antacids.”

Answer 42

DU

Question 43

A patient presents with guarding, rigidity, and rebound tenderness in the stomach area?

Answer 43

Acute abdomen

Question 44

Signs of bleeding or perforation of PUD

Answer 44

Tachycardia Orthostatic BP changes Guarding, rigidity, rebound tenderness

Question 45

Textbook diagnostic evaluation for PUD

Answer 45

Barium swallow

Question 46

The most common complication of PUD.

Answer 46

GI bleed (15% of pt’s)

Question 47

Up to ______% of pt’s with ulcer-related hemorrhage bleed w/out any preceding warning signs or sx.

Answer 47

20

Question 48

Second most common ulcer-related complication.

Answer 48

Perforation

Question 49

When duodenal or gastric contents spill into the abdominal cavity and leads to an acute abdomen?

Answer 49

Free Perforation

Question 50

A form of perforation where the ulcer bed tunnels into an adjacent organ?

Answer 50

Penetration

Question 51

DU perforation usually goes to__________. GUs tend to perforate into the ____________

Answer 51

Pancreas | Left Hepatic Lobe

Question 52

What is the least common ulcer-related complication?

Answer 52

Gastric Outlet Obstruction

Question 53

A patient presents with new onset early satiety, nausea, vomiting, increasing postprandial abdominal pain, and with loss.

Answer 53

Gastric Outlet Obstruction as part of PUD

Question 54

Gastric outlet obstruction can be caused by ulcers and what else?

Answer 54

Fixed, mechanical obstruction secondary to scar formation in the peripyloric area (needs dilatation)

Question 55

PPIs result in over 90% healing a DU after _____weeks and 90% GU after_____ weeks when given_________

Answer 55

4 8 30 minutes before breakfast

Question 56

What else can you give to help manage PUD sx in addition to PPI?

Answer 56

Sucralfate (builds mucosal defense, give only first few days until PPI kicks in, 4x/day)

Question 57

A pt has been dealing with PUD for a long time. They’ve been very good about not taking NSAIDS and you have definitively ruled out that they DO NOT have H. Pylori, what would be a last resort option?

Answer 57

Refractory Ulcer Tx