Peptic Ulcer Disease Management Flashcards
What is the incidence of gastric ulcers/Duodenal ulcers?
2-2.9%
What are the main alarm symptoms?
VBAD
Who should receive an endoscopy? (4)
- New onset symptoms >50 (>60) years of age
- Any alarm symptoms
- Refractory symptoms
- At risk for Barrett’s esophagus
What are the systematic approach in patients presenting wit hdyspepsia?
1) Other possible causes?
2) Upper GI location?
3) New onset >50 (>60) or red flag symptoms?
4) NSAID use?
6) H. Pylori present?
What is the definition of Peptic Ulcer Disease?
Any breach in the mucosa of the digestive tract
What are the majority of PUD?
Gastric duodenal ulcers and differ from gastric erosions
What are the aggressive factors of PUD?
- H. Pylori ● Acid
- NSAIDs ● Ethanol
- Pepsin ● Smoking?
- Physiologic stress ● Psychologic stress?
What are the protective factors of PUD?
- Gastric mucous
- HCO3
- Prostaglandins
- Mucosal blood flow
- Epithelial cell regeneration
What is NSAID-Induced PUD?
↓ COX-1 activity = ↓ prostaglandins = predispose mucosa to injury
* Dose and duration an important determinant of risk
* Presence of dyspeptic symptoms and severity poorly correlated to PUD
There is no topical effect, hence when we even recieve NSAIDS via IV, we have these same issues
Which NSAIDs have the lowest risk profile for PUD?
Celecoxib and Ibuprofen
What NSAID have the highest risk?
Piroxicam and Ketorolac
What high dose of Celecoxib reduces the Cox-2 selectivity?
> 400mg/day
Concomitant ASA or anticoagulant increases ulcer risk
What is the determining risk of NSAID-induced ulcers?
- History of an uncomplicated ulcer
- Age >60 (++ risk >70)
- High-dose or multiple NSAID use
- Concomitant ASA, glucocorticoids, anticoagulants, antiplatelets, SSRI
- History of CVD
What is H.pylori induced PUD?
- A gram-negative rod bacteria spread by fecal – oral route
- Exclusively colonizes gastric epithelium
- Risk factors for colonization:
- Crowded living conditions
- Unclean water
- Raw vegetables
- Produces urease, which converts urea → ammonia
- Also produces phospholipase and catalase
How does H.pylori woork?
Renders underlying mucosa more vulnerable to acid damage and high levels of ammonia
(Prevents detection of acidity, and direct toxic effect on epithelial cells)
Promotes cytokine and inflammation
What is the general symptom difference between dueodenal ulcer and gastric ulcer?
Duodenal ulcer is initially relievs pain then pain 2-5 hours after a meal and at night
Gastric ulcer is immediately worsened by food
Complicaitons of PUD?
- Quality of life decrease
- GI Bleeds
- Perforations or fistulation
- Gastric outlet obstructions
- Mortality increase
What are the clinical symptoms of PUD complications with respect to bleeding?
- Nausea and vomiting
- Hematemesis
- Melena
- Orthostatic hypotension
- Red blood in stool if massive bleed (hematochezia)
What are the clinical symptoms of PUD complications with respect to obstruction?
- Nausea and vomiting
- Early satiety
- Bloating
- Indigestion
- Anorexia and weight loss
What are the clinical symptoms of PUD complications with respect to perforation or fistulas?
- Sudden change in symptom pattern
- Halitosis
- Post-prandial diarrhea
- Weight loss
What is the establishment of the cause of PUD?
H.Pylori testing and NSAID assessment use
What is the evaluation of other causes for PUD?
- Smoking history
- Acid hypersecretion
- Local ischemia
- Other ulcerogenic drugs
- H. Pylori false negative
What are the indications of H.pylori testing?
- Active or past history of PUD
- History of H. Pylori infection and recurrent symptoms
What are the methods for H.Pylori testing?
Endoscopy
Urea breath testing
Stool antigen assay
Serology
What are the risk of recurrence of PUD?
- NSAIDs
- H. Pylori suboptimal eradication or reinfection
- Smoking
- Alcohol use
- Long-standing PUD
What are the goals of therapy with respect to PUD?
- Relieve dyspepsia
- Heal the ulcer
- Prevent complications
- Prevent recurrence
- Implement lifestyle changes
- Avoid foods that trigger symptoms
- Eliminate alcohol intake
- Smoking cessation
What is the txtmnt of NSAID-induced ulcer?
Stop NSIAD
PPI standard dose
Duration (Variable)
H.Pylori testing
What is the duration of therapy for gastric ulcer healing?
8 to 12 weeks
What is the duration of therapy for Duodenal ulcer healing?
4 to 8 weeks
What are some secondary prevention of NSAID-induced PUD strategies?
Lower NSAID dose
Switch to celecoxib
Add long-term PPI
Add misoprostol
What is the secondary prevention of NSAID-induced PUD-indications?* Continued NSAID use
- Continued NSAID use
- Giant ulcer and age >50 years
- H. Pylori resistance
- Refractory peptic ulcer
- Recurrent peptic ulcer
What is the primary prevention of NSAID-Induced PUD?
- History of an uncomplicated ulcer
- Age >60 (++ risk >70)
- High-dose or multiple NSAIDs
- Concomitant ASA, corticosteroids, antiplatelet agents, anticoagulants, SSRIs
- History of CVD
What is the pharmacology of misoprostol?
- A prostaglandin analogue leading to an increase in:
- Gastric mucous
- Bicarbonate secretion
- Inhibition of basal and nocturnal gastric acid secretion
What is the indications of Misoprostol?
Treatment of duodenal ulcer
Prevention of NSAID-induced ulcers
What are the ADRs of misoprostol?
Mg+ antacids
What are the current first line drugs used for eradication regimens for H.pylori?
- PBMT - bismuth quadruple therapy
- PAMC – non-bismuth quadruple therapy
What is PBAMTCLF?
- PPIs standard doses
- Bismuth (subsalicylate, subcitrate)
- Amoxicillin
- Metronidazole
- Tetracycline
- Clarithromycin
- Levofloxacin
- Rifabutin
What is PBMT therapy?
PPI
Bismuth
Metronidazole
Tetracycline
What is PAMC therapy?
PPI
Amoxicillin
Metronidazole
Clarithromycin
When should triple therapy be used?
Only if resistance is less then 15% (Data not available(
What are the advantages of PBMT therapy?
What are the disadvantages of PBMT therapy?
What is the overall dosing regiment of PBMT?
14 days
What is the advantages of PAMC?
What is the disadvantages of PAMC?
What is the dosing regimen of PAMC?
What are the disadvantages of three regimen?
What is generally used if PAMC or PBMT failure?
PAL
PPI
Amoxicillin
Levofloxacin
What is the regimen details for sequential therapy?
Pa –> PMC
PPI BID + Amoxicillin 1000mg BID for 5 days followed by
PPI BID + clarithromycin 500mg BID + Metronidazole 500mg BID for 5 days
What is the benefit for sequential therapy for sequential therapy?
May reduce GI ADRs
What is the disadvantages for sequential therapy for sequential therapy?
Complexity
High failures rate similar to triple therapy
What are common reasons for H. Pylori induced ulcer txtmnt failure
Adherence
Incorrect regimen used
High local resistance
Confirmation of eradication for H.pylori-induced ulcer management?
- Test four weeks after completion of therapy
- Fecal stool antigen test is optimal to confirm
What is the maintenance therapy with PPIs afer H. Pylori eradication?
- Duodenal ulcer: generally not indicated…possibly 2 weeks
- Gastric ulcer: continue PPI for 8 weeks
- If continuing, reduce PPI to once daily
What are some other options for H. Pylori-induced ulcer management?
Probiotics and maybe sucralafate
Non-H. Pylori and non-NSAID ulcers
- Poor prognosis
- PPI x 4-8 weeks only option to treat
- Increase dose and duration if initial trial fails
- Reassess and consider alternate diagnosis if little improvement
- Consider long-term PPI
PUD during pregnancy and lactation
Treat as usual
PPI use: Lansoprazole, omeprazole, pantoprazole
Lactation: prefer pantoprazole
When should we defer H. Pylori eradication in pregnancy?
Untill delivery as the antibiotics, avoid tetracycline and bismuth
Refractory PUD can be defined as those
Risk of refractory disease increased by:
* Continued NSAID use
* Poor compliance
* Inadequate H.Pylori testing/eradication
* Smoking
* Genetic rapid metabolizer of PPIs
* Hypersecretory disease
