Block 1: PUD Flashcards
What are the common forms of PU?
- H pylori
- NSAID-induced
- Stress related
What are co-factors that may cause PU?
- Cigarette smoking
- Alcohol
- Gastric acid hypersecretion
- Medication nonadherence
What is H pylori?
- G- bacteria that resides between gastric mucus layer and surface epithelial
- Ability to buffer gastric pH -> urease production
- Strong adherence and motility
- Inflammation and mucosal injury from cytotoxin production (60% of strains)
What are the complications of forming an ulcer?
- Upper GI bleeeding
- Perforation (most concerning -> peritonitis -> sepsis)
- Obstruction
What are the sx of PUD
- Asymptomatic
- Epigastric pain/N
- Bloating, belching, v/hematemesis, melena
What are the general diagnostic testing for PUD?
- CBC
- Fecal occult blood
- Upper endoscopy
What are the H pylori diagnostic testing for PUD?
- Endoscopic Biopsy & Culture
- Non-endoscopic:
* Antibody detection (not for past infections)
* Urea breath test
* Fecal antigen
What are the goals to treat PUD?
- Relieve ulcer pain
- Heal the ulcer
- Prevetn ulcer recurrence -> H pylori eradication
- Reduce ulcer-related complications
How do you eracicate H. pylori?
Bismuth quadruple therapy for 10-14 days:
1. PPI or H2RA Q-BID
2. Bismuth subsalicylate 525 mg QID
3. Metronidazole 250-500 mg QID
4. Tetracycline 500 mg QID
Why don’t you give clarithomycin to children? Why is it not in quad therapy?
Effects bone and teeth
Resistance
Patient presents with a Penicillin allergy and H pylori? What quad med should you not give?
Amoxicillin
What are the indication of treating H pylori?
- Diagnosed with PUD from infection
- Dyspepsia, GERD, iron deficiecy anemia, long term aspirin, NSAIDs
What is the initial treatment for H pylori?
What are example of combo product for H pylori?
Adherence is an issue with infection.
Add on PPI for quad therapy
What are probiotics?
Living microbial species that can include anti-inflammatory and anti-oxidative mechanisms that may improve bowel microecology and general health
What are the types of probiotics?
Lactobacillus and Bifidobacterium
What are the benefits of the limitations of using Probiotics in H pylori infection?
- Limit H pylori colonization when taking antibiotics -> increase eradication rates
- Doesn’t eradicate H pyloir infection
How should you select the best H pylori regimen?
- Avoiding tetracyclines in children
- DDI/ADR
- Alcohol with metronidazole
- Non-adherence check
- PPI preferred over H2RA, no preference in which PPI is used
What are the counseling points of H pylori regimen?
- Do not drink alcoholic beverages while taking metronidazole
- Antibiotics may decrease the effectiveness of birth control
- Bismuth salicylate may cause a change in stool color
What are good predicotors of H pylori eradication?
- Antimicrobial resistance
- Duration of therapy
- Med adherence
- Genetic polymorphism
What do you do in signs of antimicrobial resistance?
- Dual antibiotics regimens utilized to decrease issue
- Substitution of similar antibiotics within a class not recommended
What do you do in initial tx failure?
Salvage tx:
1. Use antibiotics that were not used during initial therapy or from another infection
2. Guided antibiotic resistance testing
3. Use of an extended duration of tx (14 days)
4. Add bismuth
5. Penicillin allergy, consider allergy skin test to determine with amoxicillin can be used
Describe the MOA of NSAIDs?
What is the tx for NSAID induced ulcer?
- Stop the NSAID, if able to:
* Switch to Tynelol or selective COX2 inhibitor
* Unable to, PPI is first line or misoprostol
* PPI should be continued for 12 weeks if continuing the NSAID or 8 weeks if NSAID is stopped - PPI is preferred agent due to more rapid symptom relief and ulcer healing compared to sucralfate and H2RAs
How do you prevent NSAID induced ulcer?
- Co-therapy of an NSAID with PPI, H2RA, or misoprostol
- Switch to COX-2 selective NSAID
- Combination of COX-2 selective NSAID plus gastroprotective agent
What is misoprostol?
Synthetic analog of PGE1 that improves mucosal BF and stimulates gastric mucous and bicarb secretion
T-QID
Decreases risk of PUD complications
What is ADR of misoprostol?
- Nausea
- Diarrhea
- Abdominal cramping
CI in pregnacy -> increase uterine contraction -> must be on a contraceptive and negative pregnacy test
What are the risk of COX2 selective NSAIDs? BBW?
- Serious CVT events including MI and stroke
- CI in CABG surgeries
What prevention of PUD do you use for low CV risk?
Low GI risk: Nonselective NSAID
High GI risk: Nonselective NSAIDS plus PPI; celecoxib plus PPI
What prevention of PUD do you use for high CV risk?
Low GI risk: Naproxen add PPI if patient is taking aspirin
High GI risk: No NSAIds; naprozen plus PPIl low-dose celecoxib plus aspirin plus PPI may be alternative option
What is the primary cause of SRMD?
Mucosal ischemia in critically ill patients
What are the RF of SRMD?
- Mechanical ventilation >72 hr
- Coagulopathy (drugs or dx)
- Hypotension/shock
What do you use for SRMD prophylaxis?
Parenteral H2RAs: Cimetidine, Ranitidine, Famotidine
PO/NG tube PPIs: Omeprazole +/- bicarb for PO suspension, Lansoprazole, Pantoprazole
Parenteral PPI: Pantoprazole, Esomeprazole
What is the MOA of sucralfate?
Negative charged ion binds to positively chager tissue to create a physicial barrier to gastric acid
Tablets or liquid
What is the ADR of sucralfate?
- Constipation (Al3+)
- Aluminum tox in ESRD
- Bezoar formulation
What ar the counseling points of sucralfate?
- 1 g QID or 2 g BID
- Must take on an empty stomach
When should you DC SRMD prophylaxis?
Improvement in overall medical condition:
1. Resolution of risk factors
2. Discarge from ICU
3. Extubation
4. Improvement in PO intake
Many patient transition to medsurg or DC on PPI w/o approrpiate indication
