Peptic Ulcer Disease Flashcards
Causes of Dyspepsia
Most Common: GERD
Also: Peptic Ulcer Disease
Peptic Ulcer Disease
- Symptoms
- Episodic Upper Abdominal Pain
- Bloating
- Abdominal Fullness
- Nausea
Peptic Ulcer Disease
- Causes
NSAID Induced
H, Pylori
Peptic Ulcer Disease
- Diagnosis
Visualization via endoscopy
PUD vs GERD
GERD symptoms = Heartburn and Regurgitations
Dyspepsia is epigastric pain
GERD is higher up
Red Flags of Dyspepsia
Vomiting
Bleeding
Anemia
Abdominal Pain / Weight Loss
Dysphagia
VBAAD
Drugs that can cause Peptic Ulcer Disease
- Clopidogrel
- Bisphosphonates
- Sirolimus
- Crack
Peptic Ulcer Disease
- Risk Factors
- Smoking
- Alcohol
- Stress
- Genetic Factors
Uncertain: Diet
Define Gastric Ulcer
Mucosal break in the stomach or duodenum (>5mm)
Define Duodenal Ulcer
Commonly in the duodenal bulb
Define Gastric Ulcer
Commonly in the antrum and lesser curve
Define Gastritis
Inflammation associated with gastric mucosal injury
Who is Peptic Ulcers Disease common in
- Similar in Men and Women
- Increases with age
- Gastric cancer
H. Pylori
- Non-Invasive Tests
First Line: Stool Antigen Test
Urea Breath Test
Serology: Can give false positives
H. Pylori
- Invasive Tests
Gold Standard: Culture
Biopsy Rapid Urease
Histology of direct cells
H. Pylori
- What tests depend on bacteria load
- Urea Breath Test
- Stool Antigen Test
- Culture
- Biopsy Rapid Urease
- Histology
H. Pylori
- Drugs that cause false negatives
Antibiotics, Bismuth: 4 weeks
H2RA: 1 day
PPI: 1-2 Weeks
H. Pylori
- First Line Therapy
Quadruple Therapy:
- PBMT or PAMC
PBMT
- PPI
- Bismuth
- Metronidazole
- Tetracycline
PAMC
- PPI
- Amoxicillin
- Metronidazole
- Clarithromycin
PAL
- PPI
- Amoxicillin
- Levofloxacin
PAR
- PPI
- Amoxicillin
- Rifabutin
How many days is H. Pylori Treatment
14 days is better than 7 days
- Leads to better treat
H. Pylori Resistance
Metronidazole: 20%
Clarithromycin: 2-8%
Amoxicillin: <1%
Tetracycline: <3%
H. Pylori
- Treatment Pathway
First Line:
- PAMC / PBMT
Second Line:
- PAMC / PBMT
Third Line:
- PAL
Forth Line:
- PAR / Refer
Metronidazole
- Adverse Effects
- Disulfiram Reaction
- Metallic Taste
Clarithromycin
- Adverse Effects
- Altered Taste
- CYP 3A4 Inhibition
- QT Prolongation
Tetracycline
- Adverse Effects
- Photosensitivity Skin Reactions
Amoxicillin
- Adverse Effects
- Diarrhea
Bismuth
- Adverse Effects
- Darkening of Stools
- Diarrhea
H. Pylori
- Monitoring
Test 4 weeks after Antibiotics
Test 1-2 weeks after PPI
Tests can be UBT, Fecal Antigen Test, Biopsy
H. Pylori Treatment Failure
Use different first line therapy
- PAL, PAR can be used as Third/Forth Line
PAR: Should only be used at 3 or more failed treatments
Should refer after 3 failed attempts
Maintenance after H. Pylori Eradication
Uncomplicated Duodenal Ulcers
- Do not need any PPIs or H2RA
Can continue PPIs or H2RA in patients for maintenance acid suppression
When is Maintenance Acid Suppression Indicated
- Uncomplicated Gastric Ulcers
- Frequent Ulcer recurrence
- History of Gastric Bleeds
- Heavy Smoker
- NSAID Use
Duration of Maintenance Acid Suppression
8 Weeks PPI
12 Weeks H2RA
Peptic Ulcer Disease
- Pregnancy
After initial H. Pylori treatment, save treatment for H. Pylori until after pregnancy/breast feeding
Peptic Ulcer Disease
- Drug Safety
Acid Suppression is a mainstay
Unsafe in Pregnancy
- Bismuth, Fluoroquinolones, Tetracycline
Risk in Nursing Infants
- Bismuth, Metronidazole, Levofloxacin
Peptic Ulcer Disease
- H. Pylori Testing in Pregnancy
UBT
What is Functional Dyspepsia
Dyspepsia with a normal endoscopy
Functional Dyspepsia
- Non-Pharm
Reassurance
Avoidance of trigger
Psychological therapy for mood and anxiety
Functional Dyspepsia
- Pharm
- Short term PPI (4-8 Weeks)
- Tricyclic Antidepressants
–> Moderate Evidence - Prokinetic Agent (Metoclopramide, Domperidone)
–> Low Evidence
NSAID Induced Ulcer
- MOA
- Inhibition of mucosal prostaglandin synthesis
- Direct irritation
NSAIDS include
Traditional: Ibuprofen, Naproxen, Diclofenac
Salicylates: ASA, Salsalate
COX-2 Inhibitors: Celecoxib
Clinical Characteristics of H. Pylori
- Acute/Chronic
- Site
- Intragastric pH
- Symptoms
- Ulcer depth
- GI bleeding
- Chronic
- DU > GU
- More dependent
- Epigastric Pain
- Superficial
- Less severe, single vessel
Clinical Characteristics of NSAID Induced
- Acute/Chronic
- Site
- Intragastric pH
- Symptoms
- Ulcer depth
- GI bleeding
- Chronic
- GU > DU
- Less dependent
- Often Asymptomatic
- Deep
- More severe, single vessel
Clinical Characteristics of Stress Related Mucosal Damage
- Acute/Chronic
- Site
- Intragastric pH
- Symptoms
- Ulcer depth
- GI bleeding
- Acute
- GU > DU
- Less dependent
- Asymptomatic
- Most superficial
- More severe, superficial mucosal capillaries
What patients are at high risk of NSAID ulcers
- History of peptic ulcer disease
- More than 2 risk factors
NSAID Ulcers
- Risk Factors
- Older age
- NSAID use
- SSRI, ASA, Corticosteroid, Anticoagulants
- CV History
Low GI and Low CV Risks
NSAID Only
Low GI and High CV Risks
Naproxen + PPI/Misoprostol
Moderate GI and Low CV Risk
NSAID + PPI/Misoprostol
Low GI and High CV Risk
Naproxen + PPI/Misoprostol
High GI and Low CV Risk
Alternate or COX Inhibitor + PPI/Misoprostol
High GI and High CV Risk
Avoid NSAID and Avoid COX Inhibitor
NSAID Induced Ulcer
- Treatment
- If possible discontinue NSAID
- Treat the ulcer with either PPI or H2RA (PPI is superior, H2RA takes longer, Misoprostol is same as H2RA) - If NSAID is necessary
- COX-2 Inhibitor or PPI/Misoprostol Co-therapy - Test and treat H. Pylori
NSAID Induced Ulcer
- Considerations
Misoprostol is contraindicated in pregnancy
Duodenal vs Gastric Ulcer
- Time to treat
Gastric ulcers take longer to treat (8 Weeks) compared to Duodenal ulcers (4 Weeks)
Prevention of Stress Related Mucosal Bleeding
- Enteral Nutrition
- H2RA
- PPI
- Sucralfate
Deprescribing PPIs
- When are PPIs used for long term
- Barrett’s Esophagus
- Chronic NSAID use with bleeding risk
- Severe Esophagitis
- History of GI Bleed
Tapering off PPIs
25% can stop PPIs, 30-50% can decrease dose
- Decrease dose by half
- Dose every other day
- PRN
Low Bleeding Risk
- Clean Ulcer Base
- Flat Spot
- Adherent Clot
High-Rebleed Risk
Non-Bleeding Visible Vessel
Active Bleeding
How to decrease rebleed risk
- CIVI
Continuous IV Infusion:
- Pantoprazole 80 mg IV bolus, then 8 mg/hr for 72 hours
For high risk patients, or patients that are verified to still be bleeding with endoscopy: - Days 4-14 PO pantoprazole
How to decrease rebleed risk
- Intermittent Bolus
Intermittent Bolus: Pantoprazole 80 mg IV, then 40 mg IV every 12 hours
