Peptic Ulcer Disease Flashcards
Kinds of ulcers
Gastric and duodenal
What does ulcer severity tell you?
The deeper the ulcer, the more severe the damage is
How can you determine the ulcer severity?
ENDOSCOPY
Main symptom of PUD
DYSPEPSIA
PUD’s association with food
Duodenal ulcers- food helps the pain
Gastric ulcer- food makes it worse
Patients with duodenal ulcers will describe what symptom?
Pain that wakes them up at midnight-3 AM
The #1 cause of PUD is due to what?
H. pylori bacteria
H. pylori tends to cause what kind of ulcers?
Duodenal ulcers
Features of H. pylori
Spiral shape with flagellum
Adherence pedestals
Protective mechanisms against stomach acid
Protective mechanisms of H. pylori
Convert urea to ammonia and bicarb
Produces lipases and proteases to degrade mucus later
Toxin production
Induces inflammatory immune response
Diagnosis methods of PUD
Endoscopy and blood tests
Tests used to determine eradication of H. pylori infection
Breath tests and fecal antigen tests
What class of drugs is the #1 cause of drug-related toxicity in the US?
NSAIDs
How can NSAIDs cause ulcers?
Decreases prostaglandin effects
Epithelial cell turnover
Weak acids crossing into epithelial cells and getting trapped
Risk factors for NSAID-induced PUD
>65 years Past history of an ulcer or PUD Concomitant steroid use with NSAID (mostly non-selective NSAIDs) Anticoagulants (warfarin, DOACs) Antiplatelets (ASA, Plavix, P2Y12is)
How many risk factors do you need to start on PPI prophy for NSAID-induced PUD?
≥1
Diagnosis of NSAID-induced PUD
Patients describing dyspepsia symptoms
NSAID taking history
ENDOSCOPY
Alcohol use and PUD
Usually causes superficial gastritis and nothing life-threatening
What patients are at risk for stress-related mucosal bleeding due to illness PUD?
Patients who are in the hospital ICU with sepsis, mechanical ventilation, etc.
Altered defense mechanisms in patients with critical illness PUD
No acid in stomach
Decreased blood flow to GI tract due to hypotension
Release of damaging mecanisms
Major risk factors for critical illness PUD
Respiratory failure (mechanical ventilation for ≥48 hours or planning to be for ≥48h) Coagulopathy: INR >1.5 or platelets <50
How many major risk factors do you need to be at risk for critical illness PUD?
1
Minor risk factors for critical illness PUD
Sepsis, hypotension/requiring pressors, history of GI bleeding, use of high dose steroids
How many minor risk factors do you need to be at risk for critical illness PUD?
≥2
What disease can also cause critical illness PUD?
Zollinger Ellison Syndrome (gastrin-producing tumor)
Symptom of Zollinger-Ellison Syndrome
Diarrhea
PPI dosing in Zollinger-Ellison Syndrome
Dosed q8-12h!
When to suspect upper GI bleeding
Haematemesis, melina
Patients who use NSAIDs
History of PUD
Presentation of UGIB
Vomiting blood, jet black stools, epigastric pain (dyspepsia), high heart rate, low blood pressure, low hemoglobin and hematocrit
Treatment of UGIB
IV bolus of LR or NS STAT
Blood products for plasma expansion (packed RBCs)
Supplemental O2
Fresh frozen plasma for reverse anticoagulation
Epinephrine, cauterization
80mg bolus of pantoprazole or esomeprazole, then 8mg/hr infusion x72 hours OR IV pantoprazole 40mg IV BID
Target Hgb
7
Target Osat
92%
Complication of PUD
GI BLEEDING
Treatment goals of PUD
Relieve pain, heal ulcer, prevent recurrence, eliminate H. pylori if it’s the cause
How long should H. pylori treatment last?
10-14 days
H. pylori treatment: triple therapy
PPI of choice BID
Clarithromycin 500mg BID
Amoxicillin 1g BID
H. pylori treatment: bismuth quadruple therapy
PPI of choice BID
Bismuth subsalicylate or subcitrate QID
Tetracycline 500mg QID
Metronidazole 250mg QID or 500mg TID
H. pylori treatment: levofloxacin triple therapy
PPI of choice BID
Levofloxacin 500mg QD
Amoxicillin 1g BID
When to use bismuth quad therapy
FIRST-LINE!
When to use levofloxacin triple therapy
If quad therapy fails
What to use in patients with a PCN allergy but need H.pylori treatment
Bismuth quad therapy, can also use metronidazole for the ampicillin instead in triple therapy
H. pylori eradication tests
Wait 4 weeks after treatment is done, then use urea breath test or fecal antigen test
What happens if there’s no eradication?
Treatment continues
If triple therapy was used the first time, go to bismuth quad therapy
Treatment for NSAID-induced PUD
PPI for 4 weeks, but can extend to 8 weeks or longer if NSAID use continues
Prevention of NSAID-induced PUD
Switch to APAP if possible, switch to selective COX-2 NSAID if possible (celecoxib (Celebrex)), add on PPI as prophy, add prostaglandin analog (misoprostol)
Treatment for NSAID-induced PUD in patients that require both an antiplatelet and NSAID
Use celecoxib (Celebrex) when possible, add PPI to regimen
Prophylaxis for stress ulcer
H2RAs!
Ranitidine (Zantac)
Duration of prophy for stress ulcer
Continue until risk factors are gone
Management of ASA or P2Y12i (secondary prevention)
Evaluate risk vs. benefit –> risk of having a post-stent cardiac event outweighs the GI bleeding risk
Make sure bleeding stops, check hemoglobin multiple times a day. Restart antiplatelet within 1-3 days after hemoglobin stabilizes
What happens if a patient is taking ASA with no cardiac history?
D/C the ASA because the risk of GI bleeding outweighs the benefit
Selective NSAIDs
Celecoxib, meloxicam, etodolac, nabumetone
