GERD/PUD

Question 1

GERD definition

Answer 1

Heartburn > 3 months or refractory to OTC treatment
- Occurs 1-2 times a week
- Substernal burning
- Dyspepsia (bad digestion, discomfort in epigastrium, pain, burning, fullness, gnawing, bloating, early satiety)

Question 2

PUD definition

Answer 2

Main complication: GI bleeding
Often associated with food
> food helps = duodenal ulcer
> food worsens = gastric/peptic ulcer
Dyspepsia, + PAIN wakes up from sleep

Question 3

GERD alarm symptoms (higher care)

Answer 3

Chest pain - cardiac workup
Suspected GI bleed
Unexplained weight loss - cancer workup
Dysphagia or anorexia (not eating)

Question 4

GERD initial treatments

Answer 4

Self care: OTC 2 weeks, if persist - see MD

RX empiric therapy: PPI QD x 8 weeks (30 min prior to meal)

Question 5

GERD treatment for recurrent after 8 wk of PPI

Answer 5

Start on lowest dose for sx relief
> Every other day, or PRN
Take on-demand or slow titration
If still not control = + PRN H2RA as long as it isn’t frequent*
*CAN DEVELOP TOLERANCE TO FAMOTIDINE

Question 6

What to do if daily GERD therapy fails?

Answer 6

Consider BID therapy: split daily dose into two
* Ensure adherence is good
* can add H2RA at night
Too much acid reduction = bad

Question 7

Nonpharm treatment for GERD

Answer 7

small frequent meals
remain upright
don’t eat at least 3 hr before bed
Lose weight
Stop smoking
Avoid constricting clothing
Avoid trigger foods
- Fatty, alcohol, mint, chocolate
- spicy, acidic, coffee, tobacco
Medications may cause GERD

Question 8

Medications that may induce GERD

Answer 8

Anticholinergics (antihistamines, TCA)
Barbituates
DHP CCBs
tetracyclines
hormones (estrogen/progesterone)
Nitrates
NSAIDS
Theophylline
Bisphosphonates
Iron
Potassium

Question 9

Who may require long term PPI treatment?

Answer 9

1) Barrett’s esophagus – to prevent cancer
2) GERD complication = severe erosive esophagitis, stricture

Question 10

Long term consequences of acid reduction meds (PPI)

Answer 10

Poor absorption of vitamins
- B12 deficiency (IF req. acid)
Risk for bone fracture, hip fracture
C.diff, gastroenteritis
Dementia
CKD: potential for AIN - yearly monitoring

Question 11

Gastritis/duodenitis

Answer 11

Superficial, do not go past lamina priora

Question 12

Peptic/gastric/duodenal ulcer

Answer 12

Deep, go all the way to the submucosa
Opens up blood vessel = GI bleed

Question 13

PUD presentation

Answer 13

Dyspepsia (indigestion)
- Epigastric pain
- Gnawing
- Burning
- Early satiety

Question 14

Causes of PUD

Answer 14

1. H.pylori
2. NSAIDs
   Critical illness
   Alcohol use (superficial gastritis)

Question 15

H.Pylori induced PUD

Answer 15

1 cause of PUD, gram negative rod

Gastritis –> duodenal ulcer

Question 16

Diagnosis H.pylori PUD

Answer 16

1. invasive: Endoscopy (EGD) get tissue sample/culture
2. Noninvasive: antibody blood test (check for hx of exposure)
   + CONFIRM eradication (urea breath test/fecal antigen test)

Question 17

Treatment goals for Hpylori

Answer 17

Give abx to eliminate H.pylori
Give PPI to heal ulcer/relieve pain

Question 18

Treatment options for Hpylori

Answer 18

14 day treatment of
1. Bismuth quadruple therapy
2. Triple therapy

Question 19

Bismuth quadruple therapy

Answer 19

• PPI BID
• Bismuth QID
• Tetracycline 500mg QID
• Metronidazole 250 QID

Question 21

Triple therapy

Answer 21

• PPI BID
• Clarithromycin 500 mg BID
• Amoxicillin 1g BID
  if PCN allergy: Metronidazole TID

Treat for 14 days. then wait 4 weeks to confirm eradication → if not need to give another therapy

Question 22

NSAID induced PUD

Answer 22

1 drug related toxicity

25% NSAID users get PUD (2-4% get upper GI bleed)

Question 23

NSAID PUD risk factors

Answer 23

Age > 65
Previous history of PUD
Steroid use w/ NSAID
Nonselective NSAID use
Anticoagulant use w/ NSAID
Antiplatelet use w/ NSAID
HIGH dose NSAID (600-800 ibuprof)
Multiple NSAID (Ibuprof + ASA)

Question 24

NSAID PUD treatment

Answer 24

PPI QD x 4 weeks (max 8 weeks)
D/C NSAID if possible > switch to APAP

If must keep NSAID, give long term PPI QD therapy
- PPI QD x chronically

High risk patients = prophylactic daily PPI therapy

Question 25

High risk NSAID PUD patients

Answer 25

History of PUD
or
≥ 2 or more risks
- age, nonselect NSAID, DOAC/P2Y12, Steroids, mult NSAIDs, etc

Question 26

Diagnosing NSAID PUD

Answer 26

1. dyspepsia (pt sx)
2. NSAID hx use
3. endoscopy

Question 27

COX selective drugs

Answer 27

Celecoxib

Some selectivity:
- Nabumetone
- Meloxicam
- Etodolac

Question 28

NSAID PUD prevention

Answer 28

Switch to APAP (not as good for arthritis/pain)
Add PPI prevention
Add misoprostol to NSAID
Use COX2 selective NSAID (celecoxib)

Question 29

Upper GI bleed (UGIB) presentation

Answer 29

Hematemesis
Melema
Epigastric pain (dyspepsia)
tachycardic, hypotensive
Low hgb/hct/O2

Question 30

Upper GI bleed treatment

Answer 30

Restore volume
1. Give IV BOLUS isotonic solution (LR/NS)
2. If hbg<7, give PRBC (1 unit per 1 hgb)
3. Supportive care (O2 for low hgb)
4. Reverse anticoagulation (FFP or vitK)
5. Endoscopic GI lab (find bleed, cauterize, inj EPI)
6. PPI therapy
- Start pantoprazole/esomeprazole 80 mg IV bolus
- Then 8mg/hr PPI infusion or 40 mg IV BID x 3 days
- Switch to PO PPI BID x 2 weeks

Question 31

UGIB but on anticoag/antiplt drugs chronically?

Answer 31

Stent or previous CV event hx = once hbg stable, resume meds (ASA within 3 days)

If on ASA for primary prevention = D/C ASA

Question 32

PUD presentation

Answer 32

Dyspepsia (indigestion)
- Epigastric pain
- Gnawing
- Burning
- Early satiety