Antacids and Acid Supressive Medication

Question 1

Characteristicss of SRMD that is not amenable to endoscopic treatment

Answer 1

Stress Ulcers

Stress ulcers
• Usually diffuse
• Not amenable to endoscopic treatment
• Generally heal with time without intervention as
clinical status improves

Question 2

Clinical presentation of Stress Ulcers (5)

Answer 2

• Multiple superficial
lesions

• Proximal stomach bulb

• Involves superficial
capillaries

• Acute

• Caused by splanchnic
hypoperfusion

Question 3

Clinical Presentation: Peptic Ulcer

Answer 3

• Single or few deep
lesions

• Duodenum

• Typically involves
single vessel

• Chronic
• Occurs at anytime

Question 4

Definition: Endoscopically evident mucosal damage

Answer 4

Superficial lesions identified on endoscopy

MOST frequent

Question 5

Definition:Occult bleeding

Answer 5

Presence of guaiac-positive stools or nasogastric aspirate

Question 6

Definition: Overt or clinically evident bleeding

Answer 6

Appearance of coffee grounds in nasogastric aspirate, hematemesis, melena, or hematochezia, guaiac- positive stools

Question 7

Definition: Clinically significant bleeding

Answer 7

Bleeding with hemodynamic instability and/or blood transfusion

LEAST FREQUENT

• outcome that requires transfusion

Question 8

Clinically significant bleeding symptoms

Answer 8

• Bleeding + one of the following
  
  • Decrease in systolic blood pressure > 20 mm Hg within 24 h of bleed •
  • Orthostatic increase in heart rate of >20 beats/min and decrease in systolic blood pressure >10 mm Hg
  • Decrease in Hgb ≥2 g/dL + transfusion of 2 units packed red cells in 24 h OR subsequent transfusion after which Hgb did not increase by at least number of units transfused minus 2 g/dL

Question 9

Indications for stress-related bleeding

Independent risk factors

Answer 9

1.5% had clinically significant bleeding

Coagulopathy (OR 4.3, p<0.001)

• Respiratory failure requiring mechanical ventilation for ≥48 h (OR 15.6, p<0.001)
• Platelets < 50,000/mm3, INR >1.5, or aPTT >2x normal

Question 10

What are the other risk factors for stress related bleeding

Answer 10

• Spinal cord/head trauma
• Thermal injury affecting > 35% of total body surface area
• History of GI bleed within the past year
• Postoperative transplantation
• Ulcerogenic medications (nonsteroidal anti-inflammatory
drugs, aspirin, corticosteroids)

Question 11

What pH will prevent development of stress mucosal disease?

Answer 11

pH of 4 or higher will prevent stress mucosal disease

Question 12

What is the pH goal for the treatment of UGIB?

Answer 12

pH = 6

Question 13

MOA: Antacids

Answer 13

Neutralizes gastric acid (dose dependent) increases pH of the gastric contents reduces GI mucosal irritation

Question 14

MOA: Sucralfate

Answer 14

• Binds to albumin and fibrinogen on damaged GI mucosa –> viscous, adhesive substance that adheres to ulcers when pH <4

Question 15

MOA: H 2RAs

• Ranitidine
• Cimetidine • Famotidine • Nizatidine

Answer 15

• Competitively blocks histamine subtype 2
receptors on the basolateral membrane of the
parietal cells

• Inhibits gastrin secretion to reduce acid
production

• Do not reliably inhibit vagal induced gastric
secretion

Question 16

MOA: PPI

Dexlansoprazole • Lansoprazole • Esomeprazole • Pantoprazole • Omeprazole • Rabeprazole

Answer 16

• Binds irreversibly to the H+/K+
AT Pa s e p u m p

• Inhibition of hydrogen ion secretion
into the gastric lumen is inhibited

Question 17

Adverse Effects of Antacids

Answer 17

• Diarrhea (mostly with magnesium based
• Constipation
• Electrolyte imbalances (hypermagnesemia, hypophosphatemia) hypercalcemia, hypophosphatemia, hyperaluminum)

Question 18

What happens if you give a lot of Magnesium?

Answer 18

Diarrhea

Question 19

Adverse Effects of Sucralfate

Answer 19

• Not recommended for routine use

• Adverse effects
  
  • Constipation, aluminum toxicity, hypophosphatemia
  • Drug interactions – BIG THING!
    
    • Chelation - binds to lots of drugs causing inhibition of the absorption of that particular drug
  • Less efficacious than H2RAs

Question 20

H2RAs for preventing stress ulcers

Answer 20

• Dose dependent increase in gastric pH
  
  • bigger doses more adverse effects
• Tachyphylaxis will develop
  
  • Possibly due to up-regulation of alternative pathways (gastrin, acetylcholine)
• Adverse SE:
  
  • Mental Status Change
  • Thrombocytopenia
  • Rapid infusion related hypotension
  • Risk for nosocomial pneumonia

Question 21

Uses for PPI - indications OVER H2BLOCKERS

Answer 21

Uses
• Peptic ulcer disease
• Helicobacter pylori
• Chronic NSAID use
• Barrett esophagitis
• Erosive esophagitis
• Zollinger-Ellison syndrome

Question 22

The DOC for dyspepsia

Answer 22

Antacid

Question 23

When does PPI start to work?

Answer 23

maximal activity reached 3 days after initiation

• does not work right away
• SUSTAINED RELIEF

NOT USED FOR ACUTE SITUATIONS

Question 24

Adverse Effects of PPI

Answer 24

* do not discharge patient with PPI if not indicated

Question 25

Practice Considerations:

Slum dunk you should use a PPI

Answer 25

Question 26

What causes the highest rates of rebleeding?

Answer 26

• Active bleeding ulcer
• nonbleeding ulcer but vessel present at ulcer

Question 27

If you have someone with Upper GI bleed what should you do?

Answer 27

1. Do an endoscopy
2. Start PPI

Question 28

What should you use for a variceal bleed?

Answer 28

Ocreotide and or vasopressin

Question 30

Bleeding Ulcers

Answer 30

Endoscopic intervention should be done.