Peptic Ulcer Disease

Question 1

Describe PUD

Answer 1

acid-related erosion or ulceration of the GI tract extending into the mucosae

stomach and duodenum

Question 2

3 primary causes of PUD

Answer 2

NSAID-induced
H. Pylori associated
stress-related

Question 3

Aggravating factors of PUD

Answer 3

acid
pepsin
smoking
alcohol
H. pylori
NSAIDs
environmental factors
genetic factors

Question 4

helpful factors of PUD

Answer 4

prostaglandins (blood flow)
bicarbonate
mucus
growth factors

Question 5

Describe the presentation of duodenal ulcers, gastric ulcers, and both

Answer 5

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

Question 6

PUD: Alarm Symptoms

Answer 6

Bleeding
unexplained iron deficiency anemia
early satiety
unexplained weight loss
progressive dysphagia
palpable mass
recurrent emesis
family h/o GI cancer

Question 7

PUD diagnosis

Answer 7

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

Question 8

What is H. Pylori?

Answer 8

gram (-) rod that lives in stomach mucus layer, secretes cytokines (gastrin releasing peptide) that will increase production of gastric juices

Question 9

Risk factors for H. Pylori infection

Answer 9

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

Question 10

Who should get H. Pylori testing with PUD?

Answer 10

EVERYONE who has a PUD diagnosis

test again at minimum 4wk post treatment and 1-2 wk post completion PPI therapy

Question 11

List the 4 types of endoscopic testing, their adv and disadv

Answer 11

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

Question 12

List the 3 types of nonendoscopic testing

Answer 12

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)

Question 13

What are risk factors for NSAID induced ulcers and upper GI complication

Answer 13

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

Question 14

Challenges of treating H. Pylori

Answer 14

replicates at pH of 6-7
high bacterial load
emerging resistance
gastric environment

Question 15

Recommended H. pylori 1st line treatments

Answer 15

1. PCA (Clarithromycin triple therapy) PPI bid + clarithromycin 500mg bid + (amoxicillin 1g bid OR metronidazole 500mg tid)
2. PBMT (bismuth based quadruple therapy) PPI bid + bismuth subsalicylate 525mg qid + metronidazole 500mg tid-qid + tetracycline 500mg qid
3. PCA + M (concomitant therapy) PPI bid + amoxicillin 1g bid + clarithromycin 500mg bid + metronidazole 500mg bid

Question 16

Alternative H. pylori first line treatments

Answer 16

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

Question 17

No PCN allergy & No MCL exposure

Answer 17

Clarithromycin triple therapy (PCA)
Quadruple therapy (PBMT)
concomitant (PCA + M)

Question 18

No PCN allergy but yes MCL exposure

Answer 18

Quadruple (PBMT)
levofloxacin triple
levofloxacin sequential

Question 19

Yes PCN allergy & no MCL exposure

Answer 19

Clarithromycin (PCA)

Quadruple (PBMT)

Question 20

Yes PCN allergy and Yes MCL exposure

Answer 20

quadruple (PBMT)

Question 21

PPI dosing for H. pylori

Answer 21

omeprazole & rabeprazole 20mg bid
lansoprazole 30 mg bid
pantoprazole 40 mg bid
esomeprazole 40 mg DAILY
BID dosing for duration of H. pylori treatment

Question 22

PPI dosing for healing lesions (antisecretory therapy)

Answer 22

omeprazole, esomeprazole 20-40mg qd
rabeprazole 20mg qd
lansoprazole 30mg qd
dexlansoprazole 30-60mg qd
pantoprazole 40mg qd
take b4 breakfast

Question 23

Duration of antisecretory therapy based on ulcer characteristics

Answer 23

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)

Question 24

What factors are considered high risk factors for NSAID associated ulcers?

Answer 24

h/o uncomplicated ulcer
3+ moderate risk factors
dual anti-platelet therapy

Question 25

What are moderate risk factors for NSAID associated ulcers?

Answer 25

age >65yo
high dose NSAiD therapy
h/o uncomplicated ulcer
concurrent use of ASA, corticosteroids, or anticoagulants

Question 26

Who is PUD prophylaxis recommended for?

Answer 26

pts at moderate to high risk of GI toxicity

Question 27

What agents can we use for prophylaxis in patients taking NSAIDs and aspirin?

Answer 27

PPIs, misoprostol (limited by AE’s cramping and diarrhea), H2RAs (if others cannot be using)