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PMP-201 > GORD, Peptic Ulcers & H. pylori infection > Flashcards

GORD, Peptic Ulcers & H. pylori infection Flashcards

1
Q

GORD:

A

Gastro-oesophageal reflux disease

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2
Q

What is GORD caused by?

A

Usually caused by weakening/relaxation in lower oesophageal sphincter

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3
Q

Symptoms of GORD: acid from stomach leaks up into oesophagus

A

Heartburn
Acid reflux
Bad breath
Bloating / belching
Nausea / vomiting

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4
Q

Risk factors of GORD:

A

Smoking
Alcohol
Coffee
Chocolate
Fatty Foods
Being Overweight
Stress
Medicines (calcium channel blockers, nitrates, NSAIDs etc)
Tight clothing
Pregnancy

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5
Q

How to diagnose GORD?

A
  • 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

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6
Q

GORD lifestyle advice

A

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

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7
Q

GORD OTC Management

A

Antacid: Pepto-Bismol®, Rennie®

Alignate: Gaviscon Advance®

Dual Product: Gaviscon Dual Action®, Peptac®

PPI or H2 receptor antagonists

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8
Q

GORD: why take PPi or H2 instead of other OTC?

A

Longer acting, but take longer to work than antacids

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9
Q

PPI or H2 receptor antagonists - council for GORD

A

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

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10
Q

GORD red flags/ when to refer??

A

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

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11
Q

What are the red flag symptoms for GORD?

A

Unintentional weight loss
Epigastric mass
Stomach pain, pain/difficulty when swallowing
Persistent vomiting
Jaundice
Signs suggestive of GI bleed

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12
Q

GORD POM Management?

A

if CONFIDENT patient has GORD

offer full dose PPI for 4-8 weeks

PPI = Proton Pump Inhibitor

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13
Q

What if patient does not respond to PPI POM meds for GORD?

A

give H2 receptor antagonist

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14
Q

PPI doses GORD dose: lanzoprazole (proton pump inh)

A

30mg OD - full standard dose

15mg OD - low dose

30mg^2 BD - double dose

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15
Q

PPi doses GORD dose: Omeprazole (proton pump inh.)

A

20mg OD - full standard dose

10mg^2 OD - low dose

40mg OD - double dose

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16
Q

PPIs - issues?

A

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

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17
Q

H2 Receptor Antagonists
(GORD) exaples of drug

A

Examples: ranitidine, famotidine, cimetidine
BD dosing

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18
Q

H2 Receptor Antagonists
- aware of….

A

risk of masking gastric cancer

s.e > constripation, diarrhoea, fatigue, headache

interactions

supply chain - manufac. issues

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19
Q

What are peptic ulcers?

A

Sores that develop in lining of stomach and intestines
Gastric ulcer = in stomach
Duodenal ulcer = in duodenum (small intestine)

20
Q

signs and symptoms of peptic ulcers:

A

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

21
Q

Risk factors & Causes
of peptic ulcers?

A

common over 60 and in males
cause: when protective lining of stomach is damaged

22
Q

What is poeptic ulcers a RESULT of?

A
  1. Helicobacter pylori (H. pylori) infection
  2. Taking non-steroidal anti-inflammatories (NSAIDs)
  3. Sometimes caused by ‘stress’ (e.g. in intensive care) or some foods (patchy evidence)
23
Q

Why is taking on-steroidal anti-inflammatories (NSAIDs) a risk for peptic ulcers?

A

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

24
Q

Helicobacter pylori (H. pylori) infection role in causation of peptic ulcers?

A

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

25
Q

Explain the pathophysiology of peptic ulcers?

A

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

26
Q

What damaging factors are at risk to a normal human before injury that can cause peptic ulcers?

A

gastric acidity and peptic enzymes

27
Q

Pathophysiology of peptic ulcers; protective factors in a normal human:

A

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

28
Q

Complications of peptic ulcers - uncommon but lie threatening

A

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

29
Q

Diagnosis

A

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?

30
Q

Peptic ulcer POM Management

A

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

31
Q

Monitoring and follow-up???

A
  • 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

32
Q

What if symptoms of peptic ulcers persist?

A

Exclude non-adherence, inadvertent NSAID use or drugs causing ulcers
Exclude other cause, e.g. malignancy, Crohn’s, Zollinger-Ellison syndrome

33
Q

Symptoms of peptic ulcers reoccur????

A

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

34
Q

What is H.pylori?

A

gram -ive bacteria found in STOMACH

35
Q

What are the Risk factors of H.pylori?

A

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

36
Q

How is H.Pylori transferred?

A

saliva, voimit, stool of infected person

37
Q

Complications of infection

A

Peptic ulcers
Gastritis
Inflammation of stomach lining
Stomach cancer

Important to identify cases and treat properly

38
Q

Diagnosis
of H.pylori

A
  • Carbon-13 urea breath test
  • Other options are stool test or blood test
39
Q

What is the first line management for H.pylori for no pen allergy

A

amoxicillin 1g PO BD

clarythromycin 500mg PO BD or metronidazole 400mg PO BD

any PPI e.g. omeprazole 20mg PO BD

duration = 7 days

40
Q

What is the first line management for H.pylori for pen allergy

A

clarythromycin 500mg PO BD

Metronidazole 400mg PO BD

any ppi e.g. omeprazole 20mg PO BD

for 7 days

41
Q

What is the 2nd line management for H.pylori for no pen allergy

A

Amoxicillin 1g PO BD
1g PO BD

Clarythromycin 500mg PO BD

PPi e.g. omeprazole 20mg PO BD

7 days

42
Q

What is the 2nd line management for H.pylori for pen allergy

A

levoflaxacin 250mg PO BD

Metronidazole 400mg PO BD

any PPI e.g. omeprazole 20mg PO BD

7 days

43
Q

Management – 3rd Line
H.pylori

A

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

44
Q

points to consider - H.Pylori

A

strain may be resistant

diarrhoea

adherence

45
Q

Bismuth ?

A

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

46
Q

potential issue for treatment failure - H.pylori

A
  • poor compitence with meds
  • resistant H.pylori strains
  • prior use of regimen antibiotics
  • inadequate suppression of stomach acid during treatment
47
Q

Monitoring and follow up
- H.pylori

A

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

PMP-201 (34 decks)

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