GERD/PUD Flashcards
GERD definition
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)
PUD definition
Main complication: GI bleeding
Often associated with food
> food helps = duodenal ulcer
> food worsens = gastric/peptic ulcer
Dyspepsia, + PAIN wakes up from sleep
GERD alarm symptoms (higher care)
Chest pain - cardiac workup
Suspected GI bleed
Unexplained weight loss - cancer workup
Dysphagia or anorexia (not eating)
GERD initial treatments
Self care: OTC 2 weeks, if persist - see MD
RX empiric therapy: PPI QD x 8 weeks (30 min prior to meal)
GERD treatment for recurrent after 8 wk of PPI
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
What to do if daily GERD therapy fails?
Consider BID therapy: split daily dose into two
* Ensure adherence is good
* can add H2RA at night
Too much acid reduction = bad
Nonpharm treatment for GERD
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
Medications that may induce GERD
Anticholinergics (antihistamines, TCA)
Barbituates
DHP CCBs
tetracyclines
hormones (estrogen/progesterone)
Nitrates
NSAIDS
Theophylline
Bisphosphonates
Iron
Potassium
Who may require long term PPI treatment?
1) Barrett’s esophagus – to prevent cancer
2) GERD complication = severe erosive esophagitis, stricture
Long term consequences of acid reduction meds (PPI)
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
Gastritis/duodenitis
Superficial, do not go past lamina priora
Peptic/gastric/duodenal ulcer
Deep, go all the way to the submucosa
Opens up blood vessel = GI bleed
PUD presentation
Dyspepsia (indigestion)
- Epigastric pain
- Gnawing
- Burning
- Early satiety
Causes of PUD
- H.pylori
- NSAIDs
Critical illness
Alcohol use (superficial gastritis)
H.Pylori induced PUD
1 cause of PUD, gram negative rod
Gastritis –> duodenal ulcer
Diagnosis H.pylori PUD
- invasive: Endoscopy (EGD) get tissue sample/culture
- Noninvasive: antibody blood test (check for hx of exposure)
+ CONFIRM eradication (urea breath test/fecal antigen test)
Treatment goals for Hpylori
Give abx to eliminate H.pylori
Give PPI to heal ulcer/relieve pain
Treatment options for Hpylori
14 day treatment of
1. Bismuth quadruple therapy
2. Triple therapy
Bismuth quadruple therapy
- PPI BID
- Bismuth QID
- Tetracycline 500mg QID
- Metronidazole 250 QID
Triple therapy
- 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
NSAID induced PUD
1 drug related toxicity
25% NSAID users get PUD (2-4% get upper GI bleed)
NSAID PUD risk factors
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)
NSAID PUD treatment
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
High risk NSAID PUD patients
History of PUD
or
≥ 2 or more risks
- age, nonselect NSAID, DOAC/P2Y12, Steroids, mult NSAIDs, etc
Diagnosing NSAID PUD
- dyspepsia (pt sx)
- NSAID hx use
- endoscopy
COX selective drugs
Celecoxib
Some selectivity:
- Nabumetone
- Meloxicam
- Etodolac
NSAID PUD prevention
Switch to APAP (not as good for arthritis/pain)
Add PPI prevention
Add misoprostol to NSAID
Use COX2 selective NSAID (celecoxib)
Upper GI bleed (UGIB) presentation
Hematemesis
Melema
Epigastric pain (dyspepsia)
tachycardic, hypotensive
Low hgb/hct/O2
Upper GI bleed treatment
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
UGIB but on anticoag/antiplt drugs chronically?
Stent or previous CV event hx = once hbg stable, resume meds (ASA within 3 days)
If on ASA for primary prevention = D/C ASA
PUD presentation
Dyspepsia (indigestion)
- Epigastric pain
- Gnawing
- Burning
- Early satiety
