Peptic Ulcer Disease Flashcards
Describe PUD
acid-related erosion or ulceration of the GI tract extending into the mucosae
stomach and duodenum
3 primary causes of PUD
NSAID-induced
H. Pylori associated
stress-related
Aggravating factors of PUD
acid pepsin smoking alcohol H. pylori NSAIDs environmental factors genetic factors
helpful factors of PUD
prostaglandins (blood flow)
bicarbonate
mucus
growth factors
Describe the presentation of duodenal ulcers, gastric ulcers, and both
Duodenal - before age 40, some NSAID association, pain on empty stomach (2-5 hr after eating), food alleviates pain
Gastric - after age 40 (>60 yo), strong NSAID association, pain after eating
Both - diffuse epigastric pain, can be painless, dyspepsia possible, may lead to significant bleeding, hemorrhage, or obstruction
PUD: Alarm Symptoms
Bleeding unexplained iron deficiency anemia early satiety unexplained weight loss progressive dysphagia palpable mass recurrent emesis family h/o GI cancer
PUD diagnosis
routine lab testing not helpful
upper endoscopy
biopsy: duodenal ulcers - ok to defer if no alarm symptoms; gastric ulcers - recommended but ok to defer if no alarm
What is H. Pylori?
gram (-) rod that lives in stomach mucus layer, secretes cytokines (gastrin releasing peptide) that will increase production of gastric juices
Risk factors for H. Pylori infection
anything related to crowded or unsanitary living conditions year of birth birth or living in developed country institutionalization low socioeconomic status unclean food and water
Who should get H. Pylori testing with PUD?
EVERYONE who has a PUD diagnosis
test again at minimum 4wk post treatment and 1-2 wk post completion PPI therapy
List the 4 types of endoscopic testing, their adv and disadv
Histology: excellent sensitivity and specificity - $$$ requires infrastructure and trained personnel
Biopsy: inexpensive w rapid results - affected by PPIs and abx
Culture: allows determination of abx sensitivities - $$$ difficult to perform
PCR: allows determination of abx sensitivities - not widely available
List the 3 types of nonendoscopic testing
antibody testing: inexpensive, widely avail - not rec’d after H. pylori therapy
Urea breath tests: IDs active infection, rec’d in pt with acute GI bleeds - affected by PPIs, abx, bismuth
fecal antigen test: ID active infection - affected by PPIs, abx, bismuth, and active bleeding (blood in stool decr specificity)
What are risk factors for NSAID induced ulcers and upper GI complication
age >65 previous ulcer multiple NSAID use aspirin smoking alcohol H. pylori concomitant use of: NSAID and aspirin, oral bisphosphonates, corticosteroids, anticoag, antiplatelet drugs, SSRIs concomitant debilitating disorders: CVD, RA
Challenges of treating H. Pylori
replicates at pH of 6-7
high bacterial load
emerging resistance
gastric environment
Recommended H. pylori 1st line treatments
- PCA (Clarithromycin triple therapy) PPI bid + clarithromycin 500mg bid + (amoxicillin 1g bid OR metronidazole 500mg tid)
- PBMT (bismuth based quadruple therapy) PPI bid + bismuth subsalicylate 525mg qid + metronidazole 500mg tid-qid + tetracycline 500mg qid
- PCA + M (concomitant therapy) PPI bid + amoxicillin 1g bid + clarithromycin 500mg bid + metronidazole 500mg bid
Alternative H. pylori first line treatments
Sequential therapy: PPI bid + amoxicillin 1g bid followed by PPI bid + clarithromycin 500mg bid + metronidazole 500mg bid
Hybrid therapy: PPI bid + amoxicillin 1g bid followed by PPI bid + amoxicillin 1g bid + clarithromycin 500mg bid + metronidazole 500mg bid
Levofloxacin triple therapy: PPI bid + levofloxacin 500mg daily + (amoxicillin 1g bid OR metronidazole 500mg bid)
Levofloxacin sequential therapy: PPI bid + amoxicillin 1g bid followed by PPI bid + amoxicillin 1g bid + levofloxacin 500mg daily + metronidazole 500mg bid
No PCN allergy & No MCL exposure
Clarithromycin triple therapy (PCA)
Quadruple therapy (PBMT)
concomitant (PCA + M)
No PCN allergy but yes MCL exposure
Quadruple (PBMT)
levofloxacin triple
levofloxacin sequential
Yes PCN allergy & no MCL exposure
Clarithromycin (PCA)
Quadruple (PBMT)
Yes PCN allergy and Yes MCL exposure
quadruple (PBMT)
PPI dosing for H. pylori
omeprazole & rabeprazole 20mg bid lansoprazole 30 mg bid pantoprazole 40 mg bid esomeprazole 40 mg DAILY BID dosing for duration of H. pylori treatment
PPI dosing for healing lesions (antisecretory therapy)
omeprazole, esomeprazole 20-40mg qd rabeprazole 20mg qd lansoprazole 30mg qd dexlansoprazole 30-60mg qd pantoprazole 40mg qd take b4 breakfast
Duration of antisecretory therapy based on ulcer characteristics
Non-complicated ulcers: 14 days, d/c after abx for H. pylori
Complicated ulcers: BID PPI x 4wk, then daily PPI
complicated gastric ulcers - 8-12wk total PPI therapy & must verify healing with endoscopy
complicated duodenal ulcers - 4-8wk total PPI therapy
Continued NSAID therapy (incl aspirin): maintainence daily antisecretory therapy x 2-5 years (taper off PPI)
What factors are considered high risk factors for NSAID associated ulcers?
h/o uncomplicated ulcer
3+ moderate risk factors
dual anti-platelet therapy
