GERD/PUD

Question 1

Heartburn

Answer 1

Burning sensation in chest that moves up back of throat

Question 2

OTC treatment for Heartburn/GERD

Answer 2

1. Antacids (Tums)
2. H2RAs (Famotidine)
3. PPIs (Omeprazole) x14 days

Question 3

Dyspepsia

Answer 3

“Indigestion” - discomfort in epigastrium (midline)
Gnawing/Pain/Fullness
May be meal independent

Question 4

When to initiate Rx therapy for GERD

Answer 4

Symptoms 1-2 times per week for ~3 months
Failure to respond to OTC therapy

Question 5

GERD Alarm Symptoms (require GI workup)

Answer 5

Chest Pain (rule out cardiac causes)
GI Bleeding
Unexplained weight loss
Dysphasia
Anorexia (dec appetite)

Question 6

Empiric therapy for GERD/PUD

Answer 6

PPI QD x 8 weeks

Question 7

GERD S/Sx

Answer 7

Substernal Pain
Sour/Spicy taste in back of throat

Question 8

Treatment if unresolved after stopping empiric therapy for GERD

Answer 8

Lowest dose of PPI possible that relieves symptoms

Question 9

Treatment if empiric therapy FAILS for GERD

Answer 9

a. Titrate to PPI BID therapy (ensuring proper adherence)

b. PPI QD + H2RA at night (may develop H2RA tolerance)

Question 10

Lifestyle Modifications for GERD

Answer 10

Small, frequent meals
Remain upright after eating
Weight loss
Smoking cessation
Prop head of bed with foam wedge
Avoid trigger foods (spicy, acidic, caffeine, tobacco)
Avoid tight fitting clothes

Question 11

When is long term therapy for GERD required

Answer 11

Barrett’s Esophagus
GERD complications (strictures, erosive esophagitis)

Question 12

PPI long-term ADEs

Answer 12

Inc risk bone fracture
C. Diff/Gastroenteritis
B12 deficiency
CKD (due to Acute Interstitial Nephritis)
Dementia

Question 13

3 year RCT - What was only relevant ADE from long-term PPI?

Answer 13

Gastroenteritis

Question 14

PUD S/Sx

Answer 14

Dyspepsia #1
Epigastric pain/gnawing
Early satiety
Pain that awakens from sleep
GI bleed

Question 15

PUD Causes

Answer 15

H. pylori, NSAIDs

Question 16

Diagnosis for H. Pylori

Answer 16

a. Invasive:
- *Endoscopic - tissue culture

b. Noninvasive:
- *Antibody blood test
- Urea breath test - confirms eradication
- Fecal antigen test - confirms eradication

Question 17

PUD Therapies - H. pylori

Answer 17

1st line - Bismuth Quad Therapy
1. PPI BID
2. Bismuth subsalicylate 500 BID
3. Tetracycline 500 QID
4. Metronidazole 250 QID

2nd line - Triple therapy
1. PPI BID
2. Clarithromycin 500 BIID
3. Amoxicillin 1g BID

Question 18

Duration of H. Pylori treamtent

Answer 18

14 days (for both)

Question 19

NSAID ulcers RFs

Answer 19

Previous history PUD #1
Age > 65
Concomitant steroids
Non-COX2 selective NSAIDs
Anticoagulants
Antiplatelets
High Doses
Multiple NSAIDs (including Aspirin)

Question 20

PUD Therapies - NSAID

Answer 20

4-8 weeks daily PPI use if the NSAID can be D/C. If not, then consider long term therapy

Question 21

NSAID alternatives

Answer 21

APAP
Misoprostol + NSAID
Cox-2 selective NSAID

Question 22

Preferred COX2-selective NSAIDs

Answer 22

*Celecoxib
Nabumetone
Meloxicam
Etodulac

Question 23

PUD: Who qualifies for daily PPI therapy?

Answer 23

a. History of PUD
b. >/= 2 risk factors and taking ASA + P2Y12

Question 24

UGIB S/Sx

Answer 24

Black Stools
Hematemesis
Lightheadedness
Chest Pain
Low Hemoglobin/Hemacrit
Low BP/High HR

Question 25

UGIB Therapies - Depends on the patient

Answer 25

NS/LR Bolus to restore intravascular volume
Packed RBCs if Hgb <7
O2 supplement if needed
Reverse anticoagulation if they are on anticoagulants
Then endoscopic treatment

Question 26

UGIB Therapies - within first 72 hours

Answer 26

80mg bolus of IV PPI, then 8 mg/hr infusion
OR
40mg IV BID

Question 27

UGIB Therapies - beyond first 72 hours

Answer 27

PO PPI BID for at least 2 weeks
Additional 2 weeks if they are on an NSAID
Consider extending therapy if necessary
Add ABX if needed