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64: Peptic Ulcer Disease Flashcards

1
Q

Peptic Ulcer Disease

A

-large ulcersthat extend deeper into muscalaris mucosa
-gastric or duodenal

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2
Q

PUD epidemioligy

A

-lifetime 5-10%
-H. pylori 30-40%
-30-50% of chronic NSAID users

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3
Q

Contibuting factors to PUD

A

-h. pylori
-NSAID use
-gastric acid + pepsin
-cigs
-critical illness
-dietary factors

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4
Q

PUD pathophysiology

A

-acid and pepsin overcome mucosal defense

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5
Q

Clinical presentation of h. pylori PUD

A

-chronic
-duodenum more than tummy
-more dependent on gas pH
-superficial ulcer
-less severe GI bleeding

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6
Q

NSAID and stress PUD clinical presentation

A

-chronic
-stomach more than duodenum
-less dependent on gas pH
-often asymptomatic
-more severe bleeding
-deep ulcers from NSAIDs
-most superficial ulcers from stress

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7
Q

PUD complications

A

-GI bleed
-GI perforation
-GI obstruction (life threatenting)

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8
Q

Signs and symptoms of PUD

A

-epigastric pain
-nausea
-belching, heartburn
-weight loss
-nausea
-bloating
-early satiety

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9
Q

Goals of PUD care

A

-relieve symptoms
-heal ulcer
-prevent recurrence and complications
-eradicate or withdrawal of offending agent

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10
Q

Non-pharma tx of PUD

A

-stress reduction
-smoking cessation
-avoid food and drink triggers
-avoid NSAIDs
-surgery

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11
Q

H. Pylori induced PUD

A

-bacteria bind to wall
-colonize gastric acid
-acid damages tissue and leads to ulcer

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12
Q

H. pylori PUD diagnosis

A

-endoscopy
-antibody detect
-urea breath test
-fecal antigen

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13
Q

Principles of H. Pylori Tx

A

-several diff regimens
-usually consist of acid suppressor + 2-3 antibiotics
-helpful to determine if patient has had any recent antibiotic exposure to predict resistance

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14
Q

H. Pylori Tx options

A

-Bismuth
-Clarithromycin
-Levofloxacin
-Rifabutin
-Vonoprazan

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15
Q

Bismuth salts

A

-inhibit aggressive factors and inc protective factors
=bacterizidal
-DO NOT USE in kids UNDER 12

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16
Q

Bismuth Quadruple therapy

A
  1. PPI BID
  2. Bismuth 525mg QID
  3. Metronidazole 250-500mg QID
  4. Tetracycline 500mg QID

10-14 days

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17
Q

Helidac

A

-daily admin package
-14 blister cards w metro, terta, and bismuth
-must also take PPI BID

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18
Q

Pylera

A

-3in1 capsule
-bismuth (140mg), metro, (125mg) tetra (125mg)
-3 caps QID for 10 days
-must take w PPI BID

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19
Q

Clarithromycin Concomitant therapy

A
  1. PPI BID
  2. Clarithromycin 250-500 BID
  3. Amoxicillin 1g BID
  4. Metronidazole 250-500mg BID

-10-14 days

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20
Q

Clarithromycin sequentail therapy

A

PPI and amox the whole time or first half
-add metro and clar for last half

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21
Q

Levofloxacin therapy option

A

-triple
-quad
-sequential

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22
Q

Levofloxacin trip therapy

A
  1. PPI BID
  2. Levofloxacin 500mg qd
  3. Amox 1 g BID

-10-14 days

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23
Q

Levofloxacin Quad therapy

A
  1. Levo 250mg qd
  2. Omeprazole or other PPI at high dose qd
  3. Nitazoxanide 500mg BID
  4. Doxycycline 100 mg qd

-7-10 days

24
Q

Levofloxacin Sequential

A
  1. PPI BID (day 1-10)
  2. Amox 1 g BID (day1-5)
  3. Levo qd (day 6-10)
  4. Metro BID (day 6-10)
25
Rifabutin Triple therapy
1. omeprazole 40mg q8h 2. Amox 1g q8h 3. Rifabutin 50mg 18h -14 days -no determined place in therapy
26
Vonoprazan therapy options
-dual -triple -potassium-competitive acid blocker 0inhibits H/K ATPase in parietal cells via competitive ANTAgonism of potassium -onset 2-3 hours -can also use for erosive GERD
27
Vonoprazan Dual therapy
1. Vonoprazan 20mg BID 2. Amoxicillin 1g q8h -14 days
28
Vonoprazan triple therapy
1. Vonoprazan 20mg BID 2. Amoxicillin 1g BID 3. Clarithromycin 500mg BID -14 days
29
Importance of PPIs in H/ pylori
-antisecretory effects enhance antibiotic acivity -dec acidity = inc antibiotic -higher eradication rates -H2RAs should not be used unless patient cannot tolerate PPI -PPIs not necessary beyonf 2 weeks of use for eradication
30
PPI dosing for H. pylori
-Omeprazole 20 -Pantoprazole 40 -Esomeprazole 20-40 -Lansoprazole 30
31
Probiotics
-potentially used as prophylaxis for H. pylori colonization -can be taken to supplement antibiotic therapy to inc eradication rates when compared to placebo -may also reduce effects of therapy
32
Metronidazole side effects
-acoid alcohol due to disulfram reaction
33
Clarithromycin side effects
-GI upset
34
Tetracycline side effects
-photosensitivity -avoid use in children
35
Bismuth salts adverse effects
-darkening of stool and tongue
36
Treatment considerations for H pylori
-avoid antibiotics the pt has already taken -patient adherence -consider allergies + intolerances
37
Facotrs that predict Tx outcomes for H. pylori
-antibiotic resistance -poor medication adherence -short duration of therapy -high bacterial load
38
PUD treatment failure
-confirmed by diagnostic test 4 weeks after completion of antibiotics and after PPI has been discontinued for 2 weeks
39
Patients who fail PUD should
-be referred to gastroenterologist -perform a penicillin skin test if allergy previously listed
40
If PUD Tx fails,
-select salvage therapy -chose antibiotics that were not used in previous regimen -reference specific resistance rates -use extended treatment duration of 10-14 days
41
NSAID induced PUD patho
-rule out H. pylori and confirm with endoscopy and low Hgb and Hct if ulcers are bleeding
42
Patients at high risk for NSAID GI toxicity
-hist of ulcer -multiple risk factors
43
Patients at moderate risk for NSAID GI toxicity
-over 65 years old -high dose NSAID therapy -previous history of ulcer -use of aspririn, corticosteroids, anticoagulents
44
Low risk patients for NSAID GI toxicity
-no risk factors
45
Prevention of NSAID induced ulcers
-PPI w NSAID -H2RA w NSAID -Misoprostol w NSAID -COX-2 inhibitor
46
NSAID induced ulcer dosing
ome, panto, esome 40mg qd -Lansoprazole 30mg -Famotidine 40 once or 20 BID -Cimetidine 300 QID, 200 BID, 800 qd -Misoprostol 200mcg QID w food
47
Misoprostol for NSAID induced ulcer prevention
-200mcg w food -prostaglandin E1 analog -inc mucus and bicarbonate secretion, surface active phospholipids, and gastric blood flow which inhibits secretion
48
Misoprostol side effects
-diarrhea, ab pain. N/V, headache -boxed warning abortifacient -induces labor/abortion
49
Celecoxib (Celebrex) for NSAID induced ulcer prevention
-selective CoX-2 inhibitor -anti inflammatory but preserves prostaglandins -inc CV risk -prefer Naproxen
50
NSAID treatment in LOW GI risk and HIGH CV risk
-low dose celecoxib (200mg) -Naproxen + PPI
51
NSAID treatment in LOW GI risk and LOW CV risk
-celecoxib -any ns-NSAID + PPI
52
NSAID treatment in HIGH GI risk and HIGH CV risk
-low dose celecoxib + PPI -avoid NSAIDs
53
NSAID treatment in HIGH GI risk and LOW CV risk
-celecoxib + PPI
54
NSAID-induced ulcer treatment if patient can stop NSAID
-PPI, H2RA, or sucralfate for 8 weeks
55
NSAID-induced ulcer treatment if patient can NOT stop using NSAIDs
-PPI for 12 weeks -lowest effective dose of NSAIDd -may consider continuing PPI
56
Sucralfate (Carafate)
-1g QID before meals and at bedtime -sucrose-sulfate-al complex -interacts w albumin and fibrinogen = physical barrier over ulcer for protection
57
Sucralfate (carafate) side effects
-constipation -metabolic taste -aliminum toxicity in chronic renal failure -admin on empty stomach 2 hours before or 4 hours after other medications

Therapeutics (78 decks)

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