PEPTIC ULCER DISEASE 1.2 Flashcards
What is the spectrum of morbidity in NSAID-induced disease?
Nausea and dyspepsia (50-60%), peptic ulcer (15-30%), bleeding (melena, hematemesis), perforation (1.5%/year)
What is the effect of proton pump inhibitors on NSAID-induced complications?
Proton pump inhibitors have decreased the complications over the years.
Do dyspeptic symptoms correlate with NSAID-induced pathology?
No, dyspeptic symptoms do not correlate with NSAID-induced pathology.
What are established risk factors for NSAID-induced ulcers?
Advanced age, history of ulcer, concomitant use of GCs, high dose NSAIDs, multiple NSAIDs, anticoagulant use, clopidogrel, serious multisystem disease.
What are possible risk factors for NSAID-induced ulcers?
Concomitant H. pylori infection, cigarette smoking, alcohol consumption.
What is the pathophysiology of NSAID-induced mucosal injury?
Mucosal injury occurs through interruption of prostaglandin synthesis and neutrophil adherence to gastric microcirculation.
Why are NSAIDs a common cause of pill-induced gastritis?
NSAIDs are large acids that remain non-ionized and lipophilic, allowing them to migrate across epithelial membranes, causing intracellular injury.
Is it safe to shift a rheumatoid arthritis patient to topical NSAIDs?
No, topical NSAIDs can lead to back diffusion of H+ and pepsin, causing epithelial damage.
What are the effects of enteric-coated or buffered NSAID preparations?
Enteric-coated or buffered NSAIDs are also associated with the risk of peptic ulceration.
What are the additional pro-inflammatory mediators produced by NSAIDs?
TNF and leukotrienes, via activation of the lipoxygenase pathway.
What role does H. pylori play in NSAID-induced PUD?
H. pylori and NSAIDs act as independent and synergistic risk factors for PUD and complications like GI bleeding.
How does cigarette smoking affect ulcer healing?
Cigarette smoking decreases healing rates, impairs therapy response, and increases ulcer complications.
How does genetic predisposition affect peptic ulcer disease risk?
First-degree relatives of DU patients are three times more likely to develop an ulcer. Blood Type O+ is also a risk factor.
What are chronic disorders strongly associated with PUD?
Advanced age, chronic pulmonary disease, chronic renal failure, cirrhosis, nephrolithiasis, a1-antitrypsin deficiency, systemic mastocytosis.
What are common clinical features of PUD history?
Abdominal pain, classic burning pain in the epigastrium, nausea, vomiting, tarry stools, or coffee-ground emesis.
What is the classic pain pattern in duodenal ulcers (DU)?
Pain occurs 90 minutes to 3 hours postprandial and is often relieved by food or antacids.
What is the classic pain pattern in gastric ulcers (GU)?
Pain may be precipitated by food; nausea and weight loss are more common.
What are common physical exam findings in PUD?
Epigastric tenderness, tachycardia, orthostasis, severe tenderness, board-like abdomen (perforation), succussion splash (gastric outlet obstruction).
What are the complications of PUD?
Hemorrhage, perforation, and gastric outlet obstruction.
How does PUD-related hemorrhage present?
Melena, hematemesis, or hematochezia in the case of brisk bleeding.
What is the triad for perforation in PUD?
Acute abdominal pain, tachycardia, and abdominal rigidity.
What is the typical complication of posterior duodenal ulcers?
Penetration into the pancreas, causing pancreatitis.
What is the management for gastric outlet obstruction in PUD?
Endoscopic dilation with a balloon, or surgical intervention like myotomy or gastrectomy if needed.
What are the main diagnostic tests for PUD?
Barium meal, endoscopy, biopsy.
What are the limitations of using barium meal for diagnosing PUD?
Barium meal is rarely used as a first test and has decreased sensitivity for small ulcers (<0.5 cm).
How does endoscopy compare to barium meal in detecting PUD?
Endoscopy is the current reference standard and more sensitive and specific than barium meal.
What are alarm features in PUD patients?
Age >55, family history of GI cancer, GI bleeding, jaundice, supraclavicular lymphadenopathy, palpable abdominal mass, persistent vomiting, progressive dysphagia, unintended weight loss.
What does a positive alarm feature mean in PUD diagnosis?
Presence of alarm features should prompt referral to a gastroenterologist.
How are H. pylori infections diagnosed?
Via rapid urease test, histology, culture, urea breath test, and stool antigen test.
Why is the rapid urease test for H. pylori sometimes false negative?
Recent use of PPIs, antibiotics, or bismuth can cause false negatives.
What is the most sensitive test for diagnosing H. pylori?
Endoscopy with biopsy is the most sensitive test.
How does the urea breath test help in diagnosing H. pylori?
It is simple, rapid, and useful for early follow-up, but may have false negatives after recent therapy.
Why is serology for H. pylori not ideal for early follow-up?
Serology tests for antibodies, which are not useful for early follow-up or monitoring.
What are the risks of NSAID-induced ulcers in elderly patients?
The elderly may have absent pain and present with complications like bleeding, perforation, or obstruction.
What is the most commonly used agent combination in acid neutralizing inhibitory drugs?
Aluminum hydroxide and magnesium hydroxide
What side effects are associated with aluminum hydroxide?
Constipation and phosphate depletion
What side effects are associated with magnesium hydroxide?
Loose stools; should not be used in chronic renal failure (CRF) or renal insufficiency
What is a side effect of long-term calcium carbonate use in antacids?
Mild-alkali syndrome (hypercalcemia, hyperphosphatemia, renal calcinosis)
What condition can sodium bicarbonate induce?
Systemic alkalosis
What is the purpose of combining PPIs with sodium bicarbonate?
To provide faster relief, as PPIs have delayed onset of action
What is milk-alkali syndrome?
A rare side effect from excessive calcium carbonate intake
What are the H2 receptor antagonists (H2RAs) commonly used for?
Inhibit basal and stimulated acid secretion
What are common H2RAs?
Cimetidine, ranitidine, famotidine, nizatidine
What side effects are associated with cimetidine?
Reversible gynecomastia, impotence, inhibition of cytochrome P450
What side effect is seen in patients using cimetidine long-term?
Malignancy (not well-established)
What is the most potent H2RA?
Famotidine and nizatidine
What adverse effects can H2 receptor antagonists cause?
Pancytopenia, neutropenia, anemia, thrombocytopenia
Which H2RA is most commonly linked to liver enzyme inhibition?
Cimetidine
Which H2RAs do not bind to CYP450?
Famotidine and nizatidine
What should be avoided when administering PPIs and clopidogrel together?
Potential competition with cytochrome P450 (CYP2C19)
What are common PPIs used in treatment?
Omeprazole, Esomeprazole, Lansoprazole, Rabeprazole, Pantoprazole
What is the difference between esomeprazole and omeprazole?
Esomeprazole is the S-enantiomer of omeprazole
Why is dexlansoprazole more effective for GERD with nighttime acid?
It has a dual delayed-release system
How do PPIs work in terms of absorption?
They are protonated in the acidic environment and trapped within the parietal cell’s tubulovesicular system
What is the duration of action for PPIs?
72-96 hours
What are some long-term side effects of PPIs?
Community-acquired pneumonia, Clostridium difficile, diarrhea, hip fractures, vitamin deficiencies
How do PPIs affect vitamin B12 absorption?
They inhibit intrinsic factor production, potentially leading to vitamin B12 deficiency
What is a known side effect of PPIs related to magnesium?
Magnesium deficiency
How does a PPI + clopidogrel interaction work?
PPIs and clopidogrel compete for CYP2C19 metabolism, reducing clopidogrel efficacy
What are potassium-competitive acid pump antagonists (P-CAPs)?
Newest drug class, including revaprazan, venoprazan, and tegoprazan
What does sucralfate treat?
Active ulcers, by binding to ulcerated tissue and forming a protective barrier
What are the common side effects of sucralfate?
Constipation, aluminium-induced neurotoxicity, gastric bezoar formation
What is the primary action of prostaglandin analogs?
Enhancement of mucosal defense and repair
What is a common side effect of prostaglandin analogs?
Diarrhea
Which prostaglandin analog can induce uterine contractions and bleeding?
Misoprostol
What is the recommended dose for misoprostol?
200 µg QID
Why is H. pylori treatment important?
To decrease ulcer recurrence and recurrent ulcer bleeding
What are first-line treatments for H. pylori infection?
Combination therapy (e.g., proton pump inhibitor + antibiotics) for 14 days
Which patient population is considered for H. pylori testing and treatment?
Patients with dyspepsia, previous gastric cancer, long-term NSAID use, unexplained IDA, and ITP
What is a common side effect of bismuth-containing preparations?
Black stools, constipation, darkening of the tongue
What are common side effects of tetracycline?
Rashes, hepatotoxicity (monitor SGPT and SGOT)
Why is antibiotic resistance a concern in H. pylori treatment?
Antibiotic-resistant strains are the most common cause of treatment failure
What is a proposed innovative approach for H. pylori treatment?
N-acetylcysteine (NAC) to destroy H. pylori biofilm
