GERD and PUD Flashcards
How is GERD diagnosed?
Easiest way is to just do a trial of a PPi like omeprazole. It’s both sensitive and specific
What are “alarm symptoms” for GERD (AKA indications for an endoscopy)?
- Dysphagia/Food sticking (rule out stricture or cancer)
- Iron deficiency anemia
- Wt loss
- Jaundice
- Palpable abdominal mass
- Odynophagia
- New onset and age >55 yrs old
When would you ever use ambulatory esophageal pH monitoring to diagnose or evaluate GERD?
If diagnosis is uncertain or if they don’t respond to Ppi
What are the symptoms of GERD other than burning chest pain?
Pain worse with lying down or bending forward
Pain that is non-exertional
Which ulcers should be biopsied?
All gastric ulcers, even if appear benign. No duodenal ulcers, even if look malignant.
When do you test for H. Pylori in an ulcer?
All patients with active ulcers, plus those with inactive ulcers who have never been treated for H pylori
What condition make a rapid urease test for H. Pylori less reliable?
Taking a ppi within 2 weeks, or antibiotic within 4 weeks, of the test reduces sensitivity by 25%
What is triple therapy for an ulcer and when is it used?
Ppi + amoxicillin 1 g BID+ clarithromycin 500 mg BID
Used if proven infection with H Pylroi
What are the 2 most common causes of PUD?
- NSAIDs
- H pylori
These account for >90% of cases
What symptoms of PUD would lead you to suspect zollinger-ellison syndrome and therefore want to measure serum gastrin levels?
- multiple PEPTIC ulcers
- ulcers in unusual locations
- severe esophagitis
- fat malabsorption
What are indications to start metoclopramide?
Early satiety, nausea, normal upper endoscopy, and absence of other common causes like NSAID use
^ALL must be present! So don’t start it without a normal upper endoscopy
What is functional dyspepsia?
The Rome II committee defined functional dyspepsia as the presence of abdominal pain or discomfort centered in the epigastrium and present for at least 12 weeks over the last 12 months, which cannot be explained by upper gastrointestinal investigation
What are Cameron lesions?
linear gastric ulcers in the hiatial hernia sac. Seen in 5% of pts with hiatial hernias. Can cause chronic blood loss.
What is next best step for someone with persistently + FOBT but normal upper endoscopy and other labs?
Repeat upper endoscopy (will find a source in 30-60% of repeat cases). Then repeat colonscopy. Then capsule endoscopy.
How should you manage someone that comes in with severe hematemesis?
- Empiric omeprazole IV (not oral, obviously!)
- Normal saline
- RBC infusion
Once a patient with severe hematemesis is stabilized with NS and RBC, what is the next step?
Do an upper endoscopy to provide a diagnosis/prognosis AND treat an ulcer while you’re in there if its bleeding. I guess a bleeding ulcer is more likely than bleeding esophageal varices (I think varices only occur in people with CLEAR cirrhosis like ascites, etc), and thats why you do endoscopy to check for it.
What is the % risk of rebleeding for an ulcer WITH A VISIBLE VESSEL or that has ALREADY BLEDl?
50%, unless you go patch it up with upper endoscopy
What is the % risk of rebleeding for an ulcer with a clean base?
5%
What is the first treatment step for acute variceal hemorrhage?
RBC transfusion
When is platelet transfusion indicated for treatment of acute variceal hemorrhage?
Platelet count
What is the second treatment step (after RBC transfusion) for acute variceal hemorrhage?
- Urgent esophagogastroduodenoscopy, to ligate esophageal varices and prevent early rebleeding.
- IV octreotide to reduce portal vein flow
When would aerteriography be used to stop bleeding from a peptic ulcer or tumor?
Patient is actively bleeding and endoscopic therapy didn’t work (either because the thing kept bleeding, or because it didn’t show anything because too much blood)
When is nadolol used for esophageal varices?
For primary and secondary PREVENTION of variceal bleeding. Not as acute therapy
Options to treat h pylori GERD
“Triple therapy” for 10-14 days (70-85% eradication rate):
PPI standard dose twice daily (esomeprazole is dosed once daily)
Amoxicillin 1 gram twice daily
Clarithromycin 500 mg twice daily
“Quadruple therapy” for 10-14 days (75-90% eradication rate):
PPI standard dose once or twice daily (OR ranitidine 150 mg twice daily)
Metronidazole 250 mg four times daily
Tetracycline 500 mg four times daily
Bismuth subsalicylate 525 mg four times daily
screening for h pylori
serology testing is the best. Cant use urease testing while on ppi, and its more expensive.
fecal occult blood testing can be used second line to confirm
What tests can you run to confirm the eradication of H. Pylori?
fecal antigen test + urea breath test
why is persistence of heartburn symptoms even after antacids concenring?
because it suggests PUD, which is worse than GERD (bc its an ulcer… can bleed etc)
What do you do if a GERD trial doesnt work?
If stopped ppi >2 weeks ago or antibiotics >4 weeks ago: Urea breath test
If ppi or antibiotics could cloud breath test: serology for h pylori antigen
If alarm symptoms (dysphagia, anemia, >55 yrs old, wt loss, jaundice, palpable mass): Endoscopy
What are indications for re-testing for H pylori after triple therapy to prove eradication?
- Patients with an H. pylori-associated ULCER
- Persistent symptoms despite appropriate therapy for H. pylori
- Patients with H. pylori-associated MALT lymphoma
- History of resection for early gastric cancer
- Patients planning to resume chronic NSAID therapy (ex: SLE patients)
