HELICOBACTER PYLORI Flashcards
What is the first-line triple therapy treatment for Helicobacter pylori?
Clarithromycin, amoxicillin, and a proton pump inhibitor.
What medication can replace amoxicillin in triple therapy for Helicobacter pylori?
Metronidazole (Flagyl) can be used if necessary due to patient allergies.
Are histamine H2-receptor antagonists recommended in triple therapy for Helicobacter pylori?
No, histamine H2-receptor antagonists, such as famotidine (Pepcid), are not recommended first-line.
What is the first-line triple therapy treatment for Helicobacter pylori?
The first-line triple therapy typically consists of clarithromycin, amoxicillin, and a proton pump inhibitor.
What can be used in place of amoxicillin in triple therapy?
Metronidazole (Flagyl) can be used in place of amoxicillin if necessary due to patient allergies.
Are histamine H2-receptor antagonists recommended in triple therapy for H. pylori?
No, histamine H2-receptor antagonists, such as famotidine (Pepcid), are not recommended first-line in triple therapy.
What diagnostic tools can confirm an active H. pylori infection?
Active H. pylori infection can be confirmed with upper endoscopy with gastric biopsies, stool antigen test, and urea breath test.
What is recommended if a patient does not improve with triple therapy?
If the patient does not improve with triple therapy, quadruple therapy is recommended.
What does quadruple therapy typically include?
Quadruple therapy typically includes bismuth subsalicylate, a proton pump inhibitor, tetracycline, and metronidazole (Flagyl).
What is the recommended length of H. pylori treatment?
The recommended length of H. pylori treatment is 10–14 days.
Which medications are recommended as first-line treatment options in triple therapy for H. pylori?
Amoxicillin and a proton pump inhibitor, such as omeprazole, are recommended as first-line treatment options.
What is the role of metronidazole in triple therapy?
Metronidazole is also recommended first-line to replace amoxicillin if the patient is allergic to penicillins.
What is the diagnostic gold standard for appendix?
CT SCAN
What is a retrocaecal appendix?
An appendix located in close proximity to the psoas muscles.
How does pain present with a retrocaecal appendix?
Pain may be lateral or even posterior instead of classic RLQ pain.
What type of pain might a patient with a retrocaecal appendix present with?
The patient may present with flank pain instead of periumbilical or LRQ pain.
What is the classic triad of appendicitis?
RLQ pain, Nausea and Vomiting, Anorexia.
What is the percentage occurrence of a Pelvic Appendix?
21%
Where does the Pelvic Appendix typically descend?
Inferiorly into the pelvis.
What structures may the Pelvic Appendix be near?
Bladder, uterus, or rectum.
What is the commonality rank of Pelvic Appendix?
Second most common.
What is the classic presentation of appendicitis?
Initial vague, periumbilical pain lasting 4 to 6 hours. Pain localizes to the right lower quadrant (RQL) at McBurney’s point.
What type of pain is experienced in the initial phase of appendicitis?
Visceral pain.
What type of pain is experienced as appendicitis progresses?
Somatic pain.
What symptoms follow the onset of pain in appendicitis?
Nausea and vomiting, anorexia.
What laboratory findings may be present in appendicitis?
Mild leukocytosis and low-grade fever.
In which populations may low-grade fever be more common in appendicitis?
The elderly or immunocompromised.
Mnemonics Appendix findings
R = Rovsing’s Sign
A = Anorexia
P = Psoas sign
M = McBurney’s point tenderness
O = Obturator sign
P = Pain migrates to RLQ
ALVARADO SCORE FOR APPENDICITIS
M = Migration of the pain to RLQ =1
Anorexia = 1
N = Nausea and Vomiting =1
T = Tenderness at McBurney’s point =2
Rebound Tenderness =1
E = Elevated Temperature > 37.35 (99.5) =1
Leukocytosis = (WBC > 10,000) = 2
S = Shift to Left ((PMNs) Neutophils > 75%) = 1
Score 7 to 10 High Likelihood = Surgical consult
Score 5 to 6 Moderate likelihood = imaging required
Score < 4 Low likelihood = Consider other diagnosis.
Note in Pregnancy
Appendix displacement may cause RUQ Pain instead of RLQ Pain. Ultrasound is preferred due to radiation concerns as well as in children. MRI is second preferred if ultrasound is inconclusive.
First Line Antibiotics for appendicitis = Cefoxitin + Metronidazole
Psoas sign = Retrocaecal appendix 74%
Obturator sign = Pelvic appendicitis 21%
Alvarado score range with high probability = 7 to 10
Gold Standard Imaging for appendicitis = CT Scan with Contrast
McBurney’s Point = Point 1/3 from ASIS to umbilicus = Most tender spot in appendicitis.
Positive Psoas sign (Pain with hip extension) = Retrocaecal appendix
Positive Obturator sign (Pain with internal rotation of flexed hip) = Pelvic appendicitis.
First line imaging in children and pregnant women = Ultrasound
First line Antibiotics for uncomplicated appendix = cefoxitin + Metronidazole
First line treatment for uncomplicated appendicitis = Laparoscopic appendectomy + Preoperative IV antibiotics
First line antibiotics for appendicitis = Cefoxitin or Ceftriaxone + Metronidazole.
Positive ROVSING’S SIGN (RLQ pain when palpating the LLQ)
suggest peritoneal irritation.
Migratory pain = Periumbilical pain for e.g. 10 hours and now shifted to the RLQ.
Physical examination may show no McBurney’s point tenderness
but psoas sign may be positive (Retrocaecal appendix). Patient may complain of right sided flank pain for 24 hours (Mimicks renal or musculoskeletal issue)
Appendix may mimick UTI = Dysuria
suprapubic pain
Enlarged appendix = > 6 mm.
Gold Standard for uncomplicated cases = Laparoscopic appendectomy.
What are common characteristics of atypical appendicitis presentations in elderly patients?
Elderly patients often have delayed onset, vague pain, and lack of fever/leukocytosis.
What is the best diagnostic tool for atypical appendicitis in elderly patients?
CT Scan is the best diagnostic tool due to the subtle presentations.
Retrocaecal and pelvic appendix positions = 95% of cases.
APPENDIX POSITIONS
Retrocaecal 12 to 3 O’clock positions commonest
Pelvic = 6 O’clock position. Second most commonest.
Paracaecal = 9 0’clock position
Subcaecal = 5 position
Preileal = 9 position
Postileal = 10 to 11 position
Why the clock works = The caecum is the fixed reference bpoint in the LRQ.
Hypertension Management
Algorithm (Based on JNC 8/AHA Guidelines)
• Step 1: Assess BP Reading
• <120/80 mmHg → Lifestyle modification only
• 130-139/80-89 mmHg (Stage 1 HTN) →
Consider single-agent therapy
• ≥140/≥90 mmHg (Stage 2 HTN) → Start two-drug combination
• Step 2: Choose First-Line Agent Based on
Patient Profile
• Non-Black
<60 y/o → ACE Inhibitor or ARB
• Black patient → CCB or Thiazide diuretic
• CKD or Diabetes → ACE/ARB (renal protection)
• Step 3: Adjust Therapy Based on
Response
• If BP remains uncontrolled after 1 month
increase dose or add second agent
What is primary fatigue?
Primary fatigue includes conditions such as Depression, Fibromyalgia, and Chronic Fatigue Syndrome.
What is secondary fatigue?
Secondary fatigue can be caused by Anemia, Hypothyroidism, Sleep Apnea, or Diabetes.
What initial lab workup should be performed for fatigue?
The initial lab workup should include CBC, TSH, Iron studies, CMP, and Vitamin D.
What does low hemoglobin indicate?
Low Hemoglobin indicates Iron Deficiency Anemia.
What does elevated TSH indicate?
Elevated TSH indicates Hypothyroidism.
What does elevated glucose indicate?
Elevated glucose indicates Diabetes.
What is the management for A1C <7%?
Lifestyle modifications, Metformin
What is the management for A1C 7-9%?
Dual therapy (Metformin + GLP-1 or SGLT-2)
What is the management for A1C >9% or insulin dependence needed?
Endocrinology referral
How does the algorithm help?
Prepares for exam questions that ask: ‘What is the next best step?’
Reinforces scope of practice & appropriate referrals.
What is the systolic blood pressure range for Normal hypertension?
<120 mmHg
What is the diastolic blood pressure range for Normal hypertension?
<80 mmHg
What is the systolic blood pressure range for Pre-hypertension?
120-139 mmHg
What is the diastolic blood pressure range for Pre-hypertension?
80-89 mmHg
What is the systolic blood pressure range for Stage 1 hypertension?
140-159 mmHg
What is the diastolic blood pressure range for Stage 1 hypertension?
90-99 mmHg
What is the systolic blood pressure range for Stage 2 hypertension?
≥160 mmHg
What is the diastolic blood pressure range for Stage 2 hypertension?
≥100 mmHg
