GERD and PUD Flashcards
(113 cards)
1
Q
Gastric acid secretion is Modulated by what 3 pathways which activate their respective receptors__ __ __
A
paracrine (histamine), neuroendocrine (Ach), and endocrine (gastrin)
(H2, M3, CCK2).
2
Q
what limits extent of acid secretion?
A
Somatostatin-secreting D cells and prostaglandins
3
Q
what is the lifestyle characteristics that increase symptoms
A
High fat meals Increase in frequency of symptoms Calorically dense meals Increase in esophageal acid exposure Tobacco Increase in frequency of symptoms
4
Q
what does not change symptoms of GERD?
A
alcohol intake and caffeine
5
Q
what are the 4 mechanisms of GERD
A
Decreased Lower Esophageal Sphincter Pressure
Prolonged Esophageal Clearance
Mucosal Resistance
Delayed Gastric Emptying Time
6
Q
what is the normal fxn of LES
A
Tonic, contracted state, relaxing to permit free passage of food into stomach
7
Q
what are transient LES relaxations
A
not assoc with swallowing, Mechanism unclear, possible causes: esophageal distention, vomiting, belching, retching
8
Q
what is responsible for 65% of reflux in GERD
A
transient LES relaxations
9
Q
what meds can cause decreased LES? lots
A
Anticholinergics Barbituates Benzodiazepines Caffeine Dihydropyridine Ca2+ channel blockers Dopamine Estrogen Ethanol Isoproterenol Narcotics Nicotine Nitrates Phentolamine Progesterone theophylline
10
Q
foods that decrease LES
A
Fatty meals Peppermint/spearmint Chocolate Caffinated drinks: Coffee Cola tea Garlic Onions Chili peppers
11
Q
50% GERD patients have
A
prolonged acid clearance
12
Q
Esophagus normally cleared by
A
peristalsis
13
Q
what does increased saliva do?
A
(stimulated by swallowing) provides bicarbonate buffer
14
Q
decreased saliva is associated with 4
A
Age
Sjogren’s syndrome
Xerostomia
Sleep
15
Q
mucous secretion in the esophagus does what?
A
function to protect esophagus Bicarbonate neutralizes acidic reflux
16
Q
what foods irritate the mucosa?
A
Spicy food
Citrus juice
Tomato juice
Coffee
17
Q
without mucous in esoph what might happen?
A
After repeat exposure, H+ ions diffuse into mucosa causing cellular acidification and necrosis
18
Q
what meds irritate the mucosa?
A
Alendronate***(drink a full glass of water then stay upright for 30 min) Aspirin Iron NSAIDS Quinidine Potassium chloride
19
Q
what Factors increase gastric volume/decrease gastric emptying
A
smoking and high fat meals
20
Q
what is the cause of post prandial reflux
A
delayed gastric emptying time
21
Q
what causes GERD in infants?
A
delayed gastric emptying time
Defects in antral motility
Complications: failure to thrive, pulmonary aspiration
22
Q
8 life-style factors of GERD
A
Exercise Weight-lifting Cycling Sit-ups Smoking Obesity High-fat meals Supine body position Tight fitting clothing Pregnancy Stress
23
Q
what are 4 typical symptoms of GERD
A
Heartburn (pyrosis)
Hypersalivation
Belching
Regurgitation
24
Q
what are 6 atypical symptoms of GERD
A
Non-allergic asthma Chronic cough Hoarseness Pharyngitis Chest pain Dental erosion
25
what is primary for diagnosing GERD
endoscopy and 24 hr amb pH monitoring
26
what are 4 complications of GERD
Esophagitis, stricture, barretts esoph and adenocarcinoma of esoph
27
```
what has symptoms of Continual pain
Dysphagia
Odynophagia
Bleeding
Unexplained weight loss
Choking
```
adenocarc of esoph
28
how do you suppress gastric acid production? 3
Antacids after meals and at bedtime
H2 histamine receptor antagonist
Covalent inhibitors of the H+, K+ -ATPase of the parietal cell (PPIs)
29
what is part of promotility therapy?
Metoclopramide (dopamine antagonist)
| Bethanechol (cholinergic agent)
30
what does elevating the head of the bed do for GERD?
increases esophageal clearance
31
Dietary modifications for GERD - 5
- Avoid foods that lower esophageal sphincter pressure (fats, chocolate, ETOH, peppermint & spearmint)
- Avoids foods that have instant effect on the esophageal mucosa (spicy foods, OJ, tomato juice, coffee)
- Include protein-rich foods, augments lower esophageal sphincter pressure
- Eat small meals and avoid eating prior to sleeping-decrease gastric volume.
- Loose weight-reduces symptoms.
32
what is Ulcers extending deep into the muscularis mucosa of the stomach
PUD
33
what are 3 common forms of PUD?
Helicobacter pylori associated
NSAID induced
Stress related mucosal damage
34
what has the following symptoms?Epigastric pain, often worse at night
Pain typically 1-3 hrs after meal and may be relieved by eating
Pain can be episodic
Duodenal ulcers
35
what has the following symptoms?Epigastric pain, often worse with food
Associated symptoms: heartburn, belching, bloating, nausea, anorexia
gastric ulcers
36
h. pylori causes the majority of what type of ulcer
Duodenal
37
NSAID causes the majority of what type of ulcer
Gastric
38
what diet is associated with PUD
In high concentrations, alcohol associated with acute gastric mucosal damage, upper GI bleed
Smoking: unclear mechanism, impairs healing, higher death rates
39
what is a gram-negative rod that colonizes the mucus on the luminal surface of the gastric epithelium
Causes inflammatory gastritis
May be linked to PUD, gastric lymphoma and adenocarcinoma
h.pylori
40
what are 3 transmission of h.pylori?
Fecal-oral
Oral-oral
Iatrogenic
41
what is the MOA of antacids? it does 3 things
neutralize acid to raise intragastric pH
Decreased activation of pepsinogen
Increased LES pressure
42
what are the benefits of antacids?
rapid onset
43
what are the disadvantages of antacids?
short duration
44
what Adds viscous layer which acts as barrier to reflux in antacids>
alginic acid (Gaviscon)
45
what are the Gi ADR of antacids?
diarrhea or constipation
Diarrhea: magnesium
Constipation: aluminum
Gas: calcium, sodium bicarbonate
46
what can sodium bicarb do with in antacids? so what should you avoid?
Sodium bicarbonate products can cause fluid overload in pts. with CHF, renal failure, cirrhosis, pregnancy, or any salt-restricted diet; avoid in anyone taking supplemental calcium or with renal dysfunction
47
how does antacids affect drugs?
alter gastric pH, increase urinary pH, adsorbing medications, physical barrier to absorption, form insoluble complexes
48
what drugs to antacids affect?
Clincally significant:
Abx: quinolone, isoniazid, tetracycline
Ferrous sulfate, quinidine, sulfonylurea
49
Patients using medications >___ days should be evaluated for Risk of Barrett’s esophagus/
Risk of upper GI pathology
14
50
Patients excessively using antacids
considered more significant disease
51
If potential for drug interactions, separate dosages of antacids and drug by at least __ hours
2
52
what is the MOA of H2 receptor antagonists?
reversibly inhibit histamine-2 receptors on parietal cells
53
what are 2 uses of H2 antagonists?
On-demand therapy for intermittent mild to moderate GERD symptoms
Preventive dosing before exercise/meals
54
what is Less effective than PPIs in healing erosive esophagitis
H2-receptor antagonists
55
what are 3 H2 antagonists that she wants us to know?
Rantitidine, cimetidine, famotidine
56
H2 receptor antagonists are rapidly & well absorbed after what
oral admin
57
when is the pk time H2 antagonists work>
1-2 hrs
58
A large part of H2 antagonists are ___ in the urine and therefore may need a____ w/renal impairment.
excreted unchanged, reduction in dosage
59
what are the ADRs of H2 antagonists
Well tolerated
HA, somnolence, fatigue, dizziness, constipation or diarrhea
Thrombocytopenia: rare, reversible
60
what drug interactions does cimetidine have?
Inhibition of metabolism of warfarin, phenytoin, nifedipine, propranolol
61
what drugs need an Acidic environment required for absorption, so you would not use with H2 receptor antagonist
Ketoconazole, itraconazole, ferrous sulfate
62
what is true about combining antacids and H2receptor antagonist?
more effective than antacid tx alone
63
___eliminate symptoms and heal esophagitis more frequently and rapidly than other drugs
PPIs
64
what is Shown to normalize impaired quality of life caused by GERD
PPIs
65
when should PPIs be taken?
Before meals
66
5 prototypes of PPIs
```
Omeprazole (Prilosec)
Lansoprazole (Prevacid)
Esomeprazole (Nexium)
Pantoprazole (Protonix)
Rabeprazole (Aciphex
```
67
what is the MOA of PPIs?
Inhibit the action of the H+,K+ -ATPase
68
what do PPIs need to work?
acidic env
69
how long does it take to synthesize new H+,K+ -ATPase molecules
18hrs
70
what are ADRs of PPIs?
Generally uncommon
N/D/C
HA, dizziness, somnolence
71
if you take PPIs what might you have higher incidence of getting?
community-acquired pneumonia
Clinical significance unclear
Pts with asthma, COPD, immunocompromised, young or elderly may be at risk
72
what PPIs are metabolized by P450 enzymes
Omeprazole, lansoprazole, esomeprazole and pantoprazole
73
rabeprazole metabolized thru
nonenzymatic reduction pathway
74
Omeprazole and esomeprazole reduce metabolism of
Diazepam
Phenytoin
warfarin
75
what 3 things do promotility agents do?
LES incompetence, decreased esophageal clearance and delayed gastric emptying
76
what are metoclopramide, bethanechol, and cisapride?
promotility agents
77
what is contraindicated in Parkinson’s Dz, mechanical obstruction, concomitant use of other dopamine antagonists, anticholinergics, and pheochromocytoma
metoclopramide
78
what may increase acid production, not well tolerated due to cholinergic side-effects
bethanechol
79
what may cause Fatal cardiac dysrhythmia
cisapride
80
what is Not recommended for use except very mild cases of GERD
mucosal protectants
81
what is sucralfate
non-absorbable aluminum salts - mucosal protectant
82
what is Comparable to H2-receptor antagonist for mild esophagitis but Less effective in refractory esophagitis
sucralfate
83
what is the MOA of sucralfate?
When the pH is below 4, an extensive polymerization & cross-linking of sucralfate to form a sticky, viscid, yellow-white gel.
The gel adheres to epithelial cells and adheres very strongly to the base of ulcer craters.
84
what are 3 uses of sucralfate?
Effective at promoting healing in PUD
As a maintenance therapy--more efficacious in duodenal than gastric ulcers.
Used to prevent stress ulcers
85
what are More effective when administer prior to meals than after since acid is needed for activation
sucralfate and PPIs
86
what are 3 adrs of sucralfate?
Constipation—Al3+
Dry mouth
Abdominal discomfort
87
what are Drug int with sucralfate and therefore you should to what
Phenytoin Digoxin Tetracycline Ketoconazole
Fluroquinolone antibiotics
Therefore better to administer these meds 2 hours prior to sucralfate.
88
Improvement of symptoms with full dose PPIs usually
reverses with discontinuation of therapy
89
what is ineffective in GERD? 2
Full dose H2-receptor antagonist once daily not appropriate
Reduced dose PPIs
Alternate day dosing
“Weekend” therapy
90
Dose needed to control symptoms is appropriate dose for
maintenance
91
Acid suppression decreases recurrence of
esophageal strictures
92
Full dose PPIs lengthen time between
symptomatic relapses
93
what are complications of PUD
Ulceration and obstruction
94
what increases with NSAIDs use and PUD
perforation risk
95
Mortality of what ulcer perforation is higher?
gastric
96
what is caused by scarring or edema of duodenal bulb or pyloric channel land lead to gastric retention
obstruction
97
what has symptoms of Early satiety, bloating, anorexia, nausea, vomiting, weight loss that occurs over months?
obstruction
98
what is PAC?
PPI, amox, clarithr
99
what is PMC
PPI, metronidazole, and clarithr
100
what is PBMT
PPI, PeptoBismol, Metro, Tetra(or amox or clarithr)
101
what does pepto do for PUD? 5
-Cytoprotection through enhanced secretion of mucus and HCO3-.
-Inhibit pepsin activity.
-Accumulate bismuth subcitrate in craters of gastric ulcers.
-Antibacterial effects:
Reduce bacterial adherence to mucosal cells
Damage bacterial cell walls.
-Promote healing of both gastric and duodenal ulcers
102
what is the MOA for prostaglandin analogs? and what is an ex
Misoprostol is a synthetic analogue of prostaglandin E.
Imitates the action of endogenous prostaglandins (PGE2 and PGI2) in maintaining the integrity of the gastroduodenal mucosal barrier.
Promotes healing.
103
what is indication for prostaglandin analogs?
Ulcer healing
| Ulcer prophylaxis w/NSAID use
104
what are contraindications for Pg analogs?
Hypotension
Breastfeeding
Pregnant
105
what is ADRs of PG analogs?
diarrhea and constipation
106
in PUD elim or reduce what things? 3
```
Psychological stress
Cigarette smoking
The use of NSAIDs including aspirin
Consider APAP
Lowering the dose
Nonacetylated salicylate (salsalate)
Relatively selective COX-2 inhibitors (nabumetone, etodolac) or highly-selective COX-2 inhibitors (celecoxib)
Co-administration w/H2 antagonist or PPI
```
107
what are diet changes you can make for PUD?
Avoid food and beverages that cause dyspepsia or exacerbate ulcer symptoms
Spicy foods
Caffeine
ETOH
108
what is H pylori linked to?
PUD, gastric lymphoma, and adenocarcinoma
109
what are complications of H.Pylori?
Zollinger ellison syndrome, and Upper GI bleed, perforation, and obstruction
110
What is ZE syndrome?
Gastric acid hyper secretion and recurring ulceration from a gastrin secreting tumor
111
how do you treat ZE syndrom?
PPI and chemo
112
what presents as insidious occult blood, melana, or hematemesis?
upper GI bleed
113
3 ways to treat PUD
PAC, PMC, PBMT(adds pepto)
