4. GERD, PUD, And Related Disorders Flashcards
What are the 3 main parts of the mucosal defense system?
Mucous Gel Layer
Surface epithelial cells
Subepithelial elements
Composition of mucous gel layer
95% water and 5% mucin
Which part of the mucosal defense system serves as a barrier protection?
Mucous gel layer
Which part of the mucosal defense system provides cell protection and regeneration?
Subepithelial elements
Which part of the mucosal defense system produces mucus and regulates pH, and produces protective heat shock proteins that prevent protein desaturation?
Surface epithelial cells
Considered the “housekeeping elements”.
COX-1
Exacerbating factors of GERD regardless of causative factor.
Abdominal obesity Pregnancy Gastric hypersecretory states Delayed gastric emptying Disruption of esophageal peristalsis Gluttony
Excessive reflux of gastric contents back through the LES
GERD
The TWO most common GERD Sx. “Hallmark”
HEARTBURN and REGURGITATION
Less common GERD Sx.
Dysphagia
Chest Pain
“The great imitator”
Biliary colic
Pain associated with a bad gallbladder, can present in many ways.
Biliary colic
The DOMINANT clinical strategy for GERD
Lifestyle modifications + Empirical Tx with acid inhibitors
How long should you try the initial tx for GERD before checking on symptomatology?
8-12 wks
What are important exceptions to the GENERAL approach to tx for GERD?
PERSISTANT DYSPHAGIA or CHEST PAIN
What foods reduce LES pressure?
Fatty foods ETOH Spearmint/Peppermint Tomato-based foods Coffee/tea
Does reducing the acidity of gastric juice prevent reflux?
No, just decreases sx and allows esophagitis to heal
The most effect GERD med
PPI
What PPI do you generally start with for GERD tx?
Omeprazole (20 mg QDay x 8-12 weeks)
When should pt’s take Omeprazole (PPI’s)?
30 min BEFORE FIRST MEAL
What pt’s may need longer term PPI use?
Sx return after discontinuance of PPI
Erosive disease
Barrett’s esophagus
What is a maintenance option for pt’s without erosive disease or Barrett’s esophagus (if effective)?
H2 blockers
What is a “PPI bridge” at night?
H2 Blocker
When would you do a Nissen fundoplication?
Intractable GERD (must have a normal esophageal function proven with manometry)
When would you do a Toupet partial fundoplication tx?
Pt’s with abnormal manometry results
GERD complications
Chronic esophagitis
Bleeding
Stricture
Barrett’s Esophagus
Esophageal adenocarcinoma
What kind of cancer can Barrett’s esophagus turn into?
Adenocarcinoma
Process of Barrett’s esophagus
Squamous cells replaced with abnormal glandular-type epithelium
A pt. presents with anorexia and stomach discomfort…what is something you might consider?
Gastritis
H. Pylori is a risk factor for the development of _______________
Gastric adenocarcinoma
A pt. presents with low-grade B-cell lymphoma, what would you consider testing for?
H. Pylori
What should all patients with active PUD or hx of PUD or gastric cancer be tested for?
H. Pylori
What is the most ideal test for H. pylori?
Fecal antigen immunoassay and urea breath test?
This test demonstrates exposure of H. Pylori, but doesn’t tell us about active infection.
Quantitative Serologic ELISA test
If a pt. must stay on a PPI and you need to test for H. Pylori, what test would you use?
Endoscopic
H. Pylori eradication Tx
Omeprazole (20mg BID) + clarithromysin 500 mg BID + amoxicillin 1 g BID x 10 days
The most common type of PUD
DU
Eating relieves this type of ulcer
DU
Found in “Younger” patients (30-55)
DU
What size does a break in the mucosal surface need to be to be considered an ulcer?
> 5mm
Eating aggravates this type of ulcer.
GU
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.”
DU
A patient presents with guarding, rigidity, and rebound tenderness in the stomach area?
Acute abdomen
Signs of bleeding or perforation of PUD
Tachycardia
Orthostatic BP changes
Guarding, rigidity, rebound tenderness
Textbook diagnostic evaluation for PUD
Barium swallow
The most common complication of PUD.
GI bleed (15% of pt’s)
Up to ______% of pt’s with ulcer-related hemorrhage bleed w/out any preceding warning signs or sx.
20
Second most common ulcer-related complication.
Perforation
When duodenal or gastric contents spill into the abdominal cavity and leads to an acute abdomen?
Free Perforation
A form of perforation where the ulcer bed tunnels into an adjacent organ?
Penetration
DU perforation usually goes to__________. GUs tend to perforate into the ____________
Pancreas
Left Hepatic Lobe
What is the least common ulcer-related complication?
Gastric Outlet Obstruction
A patient presents with new onset early satiety, nausea, vomiting, increasing postprandial abdominal pain, and with loss.
Gastric Outlet Obstruction as part of PUD
Gastric outlet obstruction can be caused by ulcers and what else?
Fixed, mechanical obstruction secondary to scar formation in the peripyloric area (needs dilatation)
PPIs result in over 90% healing a DU after _____weeks and 90% GU after_____ weeks when given_________
4
8
30 minutes before breakfast
What else can you give to help manage PUD sx in addition to PPI?
Sucralfate (builds mucosal defense, give only first few days until PPI kicks in, 4x/day)
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?
Refractory Ulcer Tx
