GI 2

Question 1

what is peptic ulcer disease?

Answer 1

chronic, necrotic mucosal defect of stomach or duodenum which may cause pain, dyspepsia, nausea, vomiting, or bleeding

Question 2

what is peptic ulcer disease usually associated with?

Answer 2

gastrits (inflammation)

Question 3

signs and symptoms of PUD

Answer 3

vague or just discomfort
fullness, postprandial pain and or pre-prandial pain (hunger pain)
anorexia, weight loss
epigastric pain
nausea, vomiting, and signs of gastric obstruction
hematemesis and/or melena
anemia - iron deficiency anemia

Question 4

major complications of PUD

Answer 4

penetration
obstruction
perforation
severe GI bleeding
death

Question 5

how is PUD diagnoses?

Answer 5

EGD- you can see and biopsy stomach and duodenum

Question 6

what stimulates parietal cells to produce acid?

Answer 6

G cells –> produce gastrin

Question 7

what produces HCl in the stomach?

Answer 7

parietal cells

Question 8

what protects the stomach from the acid it produces?

Answer 8

gastric mucous: rich in prostaglandin (PGE2) and bicarbonate

Question 9

which bacteria is able to colonize in stomach despite gastric acidity?

Answer 9

H-Pylori - able to cross mucus layer of stomach

Question 10

what 4 important qualities allow H-pylori to colonize in stomach

Answer 10

mobility (flagella)
penetration
adhesiveness (glycan receptors)
induction of inflammation

Question 11

what 2 factors help H-pylori to survive despite gastric acid, cause injury, and induce cancer?

Answer 11

1. urease: an active enzyme to reduce acid concentration and to protect H. pylori in its niche
2. cytotoxin associated antigen (Cag A) causing DNA damage

Question 12

what is urease?

Answer 12

enzyme produced by H-Pylori that regulates the conversion of urea into CO2 and ammonia, which reduced gastric acidity so other HPs come in

Question 13

5 year survival for early gastric cancer

Answer 13

85%

Question 14

5 year survival for advanced gastric cancer

Question 15

stages of gastric mucosa damage

Answer 15

gastritis –>metaplasia –> dyslasia –> cancer

Question 16

most common reasons for PUD injury/loss of protection

Answer 16

H-pylori and NSAIDS (local and systemic)

Question 17

local effect of NSAIDS and PUD

Answer 17

ASA accumulates in gastric cells causing cell death

Question 18

systemic effect of NSAIDS AND PUD

Answer 18

DISRUPTING PROSTAGLANDIN SYNTHESIS AND DESTROYING GASTRIC BARRIER TO ACID WHICH CAUSES ULCER

NSAIDS block the production of PGE2 which is essential for gastric mucosa protection

Question 19

what is PUD treatment based on?

Answer 19

pathogenesis- control of acid, eradication of H-pylori, discontinue NSAIDs to protect gastric mucosa

Question 20

drugs used for acid neutralization, suppression or inhibition

Answer 20

aluminum hydroxide, magnesium hydroxide, bicarbonates- neutralize acid for a short time: H+ neutralizers (minor drugs)

H2 blockers: block the histamine effect on parietal cell and work for 4-6 hours and reduce acid (medium effect)

PPI: block formation of acid by inhibiting ATPase activity in parietal cells (most effective): PPI (omperazol)

sucralfate, bismuth, misoprostal: protection of mucosa

Question 21

what do PPIs do?

Answer 21

inhibit acid secretion (and therefore heal ulcers and eliminate pain)

Question 22

is anti acid/PPI treatment enough for PUD?

Answer 22

no, ulcers will come back unless we treat H-pylori and/or eliminate NSAIDs

Question 23

how do you get H.pylori?

Answer 23

water or fecal contamination, so this infection should be prevented by better hygiene and education

*in any EGD referral for PUD, dyspepsia, anemia or NSAIDs induced ulcer or GI bleeding look for H-pylori

Question 24

treatment of H. Pylori

Answer 24

most common: triple therapy (PPI + amoxicillin + claithromycin) 7-10 days

best!!: quadruple therapy (PPI +bismuth + metronidazole + tetracycline) for 14 days
PPI twice daily for 8 weeks
bismuth 2 tablets QID x 2 weeks
metronidazol 250 mg TID for 2 weeks
tetracycline 500 mg QID, for 2 weeks or levofloxacin; levaquin 500 mg daily

most recent: levofloxacin + amoxicillin + tinidazole + simvastatin 20 mg for 7-5 days

Question 25

treatment for PUD summary

Answer 25

treat for 8 weeks with PPI, repeat EGD only in GU
if you find h-pylori: treat for 10-14 days with antibiotics combination based on patient’s allergy and resistance history

eliminate NSAIDs
check stool h-pylori antigen 4 weeks after all drug treatments are stopped