Module 2: PUD Flashcards
What is peptic ulcer disease?
Damage to upper part of the stomach’s gastric mucosa, the first part of the small intestine, or sometimes the lower esophagus. Can be a gastric or duodenal ulcer.
How do you confirm diagnosis of PUD?
- Consider other causes e.g cardiac, hepatobiliary, medication-induced.
- Is patent >60 or any alarm features (VBAD = vomiting, bleeding, abd. mass, weight loss, dysphagia) consider organic cause = ulcer or Ca. Endoscopy.
- Is pt using NSAIDs? Stop if possible.
- Is dominant symptom heartburn? Likely GERD.
- H. pylori?
What is H. Pylori?
Type of bacteria that infects the stomach causing ulcers, gastritis and stomach cancer. Spread through contaminated food, water or utensils or direct contact with infected saliva or vomit.
What are the concerns with excessive acid suppression in the presence of H. Pylori?
Can worsen gastritis, potentially leading ot increased risk of gastric atrophy and gastric Ca.
What are the therapeutic goals for treatment of PUD?
Heal ulcer, acid suppression for prevention.
What is the therapeutic goal for NSAID related PUD?
Stop NSAID or treat as required. Goal is to eliminate and then prevent ulcers.
What is the therapeutic goal for H. Pylori related PUD?
Eliminate H. Pylori prior to acid suppression.
What is first line treatment for complicated peptic ulcer (bleeding, gastric outlet obstruction)?
- Antisecretory therapy with a PPI (IV if active bleed(
- Assess etiology of PUD
- D/C aspirin/NSAIDs
- Eradicate H. Pylori if present and confirm eradication
What is first line therapy for PUD secondary to H. pylori?
- PPI for 14 days with appropriate combination antibiotic regimen for H. Pylori: bismuth quadruple therapy (BQT) is preferred and regimen includes PPI BID
What is the dose and duration for BQT in treating H. pylori?
10-14 days
- Bismuth subcitrate 420 mg PO QID after meals and at bedtime
- Metronidazole 375mg PO QID
- tetracylcine 375mg PO QID
- Omeprazole 20mg BID
What tests are used to confirm eradication of H. pylori post treatment?
At least 4 weeks after therapy:
- urea breath test
- Fecal antigen test
- upper endoscopy
NOTE: PPI therapy withheld at least 2 weeks prior to testing
Endoscopy with biopsy for C&S in patients with persistent H. pylori after 2 courses of abx treatment.
The presence of one of the following warrants maintenance PPI’s after BQT.
- Persistent ulcer on repeat endoscopy (if performed)
- Giant (>2cm) peptic ulcer and age > 50 yrs or multiple co-morbidities
- Hx of frequently recurrent peptic ulcers (> 2 documented recurrences a year)
- condition requiring long term aspirin/NSAID use
- failure of H. pylori eradication
What are contraindications and cautions to BQT?
- Avoided or monitored in pt’s with renal failure
- Caution with mild liver impairment
- Metronidazole may accumulate with severe liver impairment
- Hx of blood dyscrasias
If on NSAIDS, hold, tx ulcer, reassess need to resume.
Numerous drug-drug interactions.
Bismuth may be neurotoxic with excessive doses.
What are special prescribing considerations for BQT?
Pregnancy & lactation = different antibiotic therapy as metronidazole and tetracycline cross placenta and into breastmilk. Resume breastfeeding 2 days after last dose.
Pediatrics= tissue hyperpigmentation, enamel hypoplasia, or permanent tooth discoloration could occur. Use of tetracycline should be avoided prior to tooth development unless absolutely needed.
What are cost/compliance considerations with BQT?
Pepto bismol - OTC
Metronidazole and Tetracylcine - partial coverage.
Omeprazole - fully covered, special authority needed.
What is the efficacy of BQT compared to clarithromycin therapy?
No efficacy. With rising clarithromycin resistance, reserved for patients whose strain shows susceptibility.
Consider length of treatment and # of pills in terms of compliance. High rate of treatment failure d/t not following the regimen.
What are common adverse effects with BQT?
- blackened stools
- Headache, dizziness
- nausea, diarrhea, abd pain, dysgeusia, dyspepsia
- Vaginitis
- weakness
What is first line therapy for aspirin/NSAID induced PUD?
- PPI (omeprazole)
- avoid aspirin/NSAIDS
- perform upper endoscopy if indicated
- assess need for continued acid suppression.
Why would a patient require maintenance PPI following tx for aspirin/NSAID induced PUD?
If the patient has any of the following:
- persistent ulcer on endoscopy (if performed)
- Giant (>2cm) peptic ulcer, >50yrs or multiple co-morbidities
- Hx of frequently recurrent peptic ulcers (>2 documented recurrences a year)
- condition requiring long term aspirin/NSAID use
What is the dose and duration of PPI therapy for aspirin/NSAID induced PUD?
Omeprazole 20mg PO OD
for ulcers<1cm: 4-6 weeks
For ulcers >1cm: 6-8 weeks
What is the role of PPI’s in the BQT?
When used alongside abx, enhance eradication of H. pylori by decreasing acidity, improving abx efficacy and patient outcomes. Decreased acidity also allow the mucosal lining to regenerate and recover effectively.
Considerations of long-term use of PPI’s?
Nutrient malabsorption and increased risk of GI infections.
What is the role of bisumuth subsalicylate in BQT?
Forms a protective layer on the gastric and intestinal mucosa, reducing irritation and inflammation caused by H. pylori, promoting healing and comfort.
