GORD, Peptic Ulcers & H. pylori infection Flashcards
GORD:
Gastro-oesophageal reflux disease
What is GORD caused by?
Usually caused by weakening/relaxation in lower oesophageal sphincter
Symptoms of GORD: acid from stomach leaks up into oesophagus
Heartburn
Acid reflux
Bad breath
Bloating / belching
Nausea / vomiting
Risk factors of GORD:
Smoking
Alcohol
Coffee
Chocolate
Fatty Foods
Being Overweight
Stress
Medicines (calcium channel blockers, nitrates, NSAIDs etc)
Tight clothing
Pregnancy
How to diagnose GORD?
- made on symptoms
- full drug history; calc antogonists, nitrates, anti-inflam drugs, corticosteroids
test like;
urea breath trest fro H. pylori infecion
Endoscopy for gastric cancers
GORD lifestyle advice
Lose weight if overweight
Eating small, frequent meals rather than large meals
Eat several hours before bedtime
Cut down on tea/coffee/cola/alcohol
Avoid triggers, e.g. rich/spicy/fatty foods
If symptoms worse when lying down, raise head of bed (do not prop up head with pillows)
Avoid tight waistbands and belts, or tight clothing
Stop smoking
GORD OTC Management
Antacid: Pepto-Bismol®, Rennie®
Alignate: Gaviscon Advance®
Dual Product: Gaviscon Dual Action®, Peptac®
PPI or H2 receptor antagonists
GORD: why take PPi or H2 instead of other OTC?
Longer acting, but take longer to work than antacids
PPI or H2 receptor antagonists - council for GORD
Do not take both at same time, one or the other
Quite strict criteria of who you can supply PPI to (recent POM to P switch)
Max 2-4 weeks treatment, then refer to GP
GORD red flags/ when to refer??
Patients over 55 years with new onset symptoms
Patients over 55 years with unexplained dyspepsia that hasn’t responded to 2 weeks of treatment
Patients who have continuously taken remedies for 4 weeks (risk of rebound indigestion)
Pregnant or breastfeeding
Not responded to OTC treatment
Red flag symptoms
What are the red flag symptoms for GORD?
Unintentional weight loss
Epigastric mass
Stomach pain, pain/difficulty when swallowing
Persistent vomiting
Jaundice
Signs suggestive of GI bleed
GORD POM Management?
if CONFIDENT patient has GORD
offer full dose PPI for 4-8 weeks
PPI = Proton Pump Inhibitor
What if patient does not respond to PPI POM meds for GORD?
give H2 receptor antagonist
PPI doses GORD dose: lanzoprazole (proton pump inh)
30mg OD - full standard dose
15mg OD - low dose
30mg^2 BD - double dose
PPi doses GORD dose: Omeprazole (proton pump inh.)
20mg OD - full standard dose
10mg^2 OD - low dose
40mg OD - double dose
PPIs - issues?
Subacute Cutaneous Lupus Erythematosus - low risk
risk:
fractures, GI infections, making gastric cancer, interactions (some interact w clopidogrel), s.e > abdo pain, nausea, vomit, constipation
H2 Receptor Antagonists
(GORD) exaples of drug
Examples: ranitidine, famotidine, cimetidine
BD dosing
H2 Receptor Antagonists
- aware of….
risk of masking gastric cancer
s.e > constripation, diarrhoea, fatigue, headache
interactions
supply chain - manufac. issues
What are peptic ulcers?
Sores that develop in lining of stomach and intestines
Gastric ulcer = in stomach
Duodenal ulcer = in duodenum (small intestine)
signs and symptoms of peptic ulcers:
Burning or gnawing pain in centre of abdomen
Indigestion
Heartburn
Nausea and vomiting
Pain can last minutes to hours, and can come and go for several days, weeks or months
Risk factors & Causes
of peptic ulcers?
common over 60 and in males
cause: when protective lining of stomach is damaged
What is poeptic ulcers a RESULT of?
- Helicobacter pylori (H. pylori) infection
- Taking non-steroidal anti-inflammatories (NSAIDs)
- Sometimes caused by ‘stress’ (e.g. in intensive care) or some foods (patchy evidence)
Why is taking on-steroidal anti-inflammatories (NSAIDs) a risk for peptic ulcers?
NSAIDs (e.g. aspirin, ibuprofen, naproxen) block COX-1 enzymes
Enzyme plays role in GI mucosal protection – if blocked, protective lining becomes vulnerable to stomach acid, causing an ulcer
Helicobacter pylori (H. pylori) infection role in causation of peptic ulcers?
Bacteria damages mucous coating of stomach and duodenum lining
Once lining is damaged, hydrochloric acid of stomach can reach the lining
The acid and the bacteria irritate the lining, causing an ulcer
Explain the pathophysiology of peptic ulcers?
in the injury - damaguing factors incl;
H. pylori infection
NSAID
Tobacco
Alcohol
Gastric hyperacidity
Duodenal-gastric reflux
which causes an increased damage or impared denenses (causes ischema/shock)
ULCER is formed:
1) necrotic debris
2) nonspecific acute inflammation
3) granulation tiussue
4) fibrosis
What damaging factors are at risk to a normal human before injury that can cause peptic ulcers?
gastric acidity and peptic enzymes
Pathophysiology of peptic ulcers; protective factors in a normal human:
1) surface mucus secretion
2) bicarbonate secretion into mucus
3) mucosal blood flow
4) epithelial barrier function
5) epithelial regenerative capacity
6) elaboration of prostaglandins
Complications of peptic ulcers - uncommon but lie threatening
Bleeding at site of ulcer
Slow bleed – anaemia
Rapid and severe – vomit blood, melaena = risk of death
Stomach perforation
GI bacteria can infect lining of abdomen – peritonitis
GI bacteria may go into bloodstream - sepsis
Gastric obstruction
Scarred or inflamed stomach can stop passage of food to gut
Will repeatedly vomit, won’t take on nutrients
Diagnosis
1) full history
2) physical abdo exam (feel mass/ listen to bowel sounds/ tap abdomen - tender, pain??)
3) urea breath test = identify H.pylori infection
REFER for endoscopy?
Peptic ulcer POM Management
due to NSAIDs?
stop if poss
Full dose PPI or H2RA therapy for 8 weeks to help ulcer heal
if due H.pylori
offer h.pylori eradication course
if due NSAIDs !AND! H/pylori
Full dose PPI or H2RA therapy for 8 weeks to help ulcer heal first
THEN offer H. pylori eradication course
not due to NSAIDs or H. pylori
Full dose PPI or H2RA for 4-8 weeks
Monitoring and follow-up???
- ensure only take PPi as a course (avoid long term)
- manage pain w/o NSAID
p[aracetamol or low-dose ibuprofen
IF want NSAID, try low dose short course of PRN basis
can consder COX-2
What if symptoms of peptic ulcers persist?
Exclude non-adherence, inadvertent NSAID use or drugs causing ulcers
Exclude other cause, e.g. malignancy, Crohn’s, Zollinger-Ellison syndrome
Symptoms of peptic ulcers reoccur????
Trial low-dose PPI, on a PRN basis
Might get rebound dyspepsia on stopping PPI, so PRN use of antacids during this time may help
What is H.pylori?
gram -ive bacteria found in STOMACH
What are the Risk factors of H.pylori?
Living in crowded conditions
Living without a reliable source of clean water
Living with someone who has H. pylori infection
More common in developing countries
How is H.Pylori transferred?
saliva, voimit, stool of infected person
Complications of infection
Peptic ulcers
Gastritis
Inflammation of stomach lining
Stomach cancer
Important to identify cases and treat properly
Diagnosis
of H.pylori
- Carbon-13 urea breath test
- Other options are stool test or blood test
What is the first line management for H.pylori for no pen allergy
amoxicillin 1g PO BD
clarythromycin 500mg PO BD or metronidazole 400mg PO BD
any PPI e.g. omeprazole 20mg PO BD
duration = 7 days
What is the first line management for H.pylori for pen allergy
clarythromycin 500mg PO BD
Metronidazole 400mg PO BD
any ppi e.g. omeprazole 20mg PO BD
for 7 days
What is the 2nd line management for H.pylori for no pen allergy
Amoxicillin 1g PO BD
1g PO BD
Clarythromycin 500mg PO BD
PPi e.g. omeprazole 20mg PO BD
7 days
What is the 2nd line management for H.pylori for pen allergy
levoflaxacin 250mg PO BD
Metronidazole 400mg PO BD
any PPI e.g. omeprazole 20mg PO BD
7 days
Management – 3rd Line
H.pylori
10 days of treatment
No penicillin allergy:
PPI + Bismuth Subsalicylate + Any 2 Abx listed not previously used
Other Abx options: Rifabutin or Furazolidone
Penicillin allergy:
PPI + Bismuth Subsalicylate + Rifabutin / Furazolidone
points to consider - H.Pylori
strain may be resistant
diarrhoea
adherence
Bismuth ?
Active ingredient in Pepto-Bismol
Link to salicylic acid
Do not give to people with aspirin allergy
Do not give to children under 16 – Reye’s syndrome
can cause tongue and faeces to turn black
potential issue for treatment failure - H.pylori
- poor compitence with meds
- resistant H.pylori strains
- prior use of regimen antibiotics
- inadequate suppression of stomach acid during treatment
Monitoring and follow up
- H.pylori
Re-testing is recommended if:
Patient was poorly compliant
High local resistance rates
Severe persistent or recurrent symptoms
Re-test at least 4 weeks (ideally 8 weeks) after treatment
Only use urea breath test to re-test
