Petic Ulcers

Question 1

What is a peptic ulcer?

Answer 1

A defect in the gastric or duodenal mucosa

Question 2

What causes a peptic ulcer to form?

Answer 2

An imbalance in factors predisposing to an ulcer (acid, pepsin, infection) and mucosal defence (mucosa, bicarbonate, PGs, NO

Question 3

What treatments are used to control acid secretion?

Answer 3

NSAIDs
Atropine
H2R antagonists
Proton pump inhibitors

Question 4

How does NSAID use lead to peptic ulcers?

Answer 4

They inhibit prostaglandin release which is important in protecting the stomach lining

Question 5

What infection is most common for causing peptic ulcers?

Answer 5

Helicobacter pylori

Question 6

What sort of drugs lead to peptic ulcers?

Answer 6

Aspirin / corticosteroids
Bisphosphonates
Nicotine
Alcohol
Caffeine

Question 7

What does helicobacter pylori do?

Answer 7

Gram negative bacillus
Undermines mucosal protection system
Secretes inflammatory proteins and toxins
Contains an enzyme urease - converts urea to NH4 and CO2

Question 8

What two ways can H Pylori be detected?

Answer 8

Carbon-13 urea breath test
Gastrointestinal endoscopy

Question 9

How is the urea breath test preformed?

Answer 9

Patient ingests urea containing non radioactive active carbon 13
CO2 is measured in breath pre and post
Cannot have been taking antibiotics or acid suppressing medications beforehand

Question 10

What sort of biopsy is preformed for H Pylori?

Answer 10

Upper gastrointestinal endoscopy with biopsy and rapid urease test
Biopsy in placed in a medium containing urea and pH indicator
Colour change when ammonia is produced

Question 11

What are principles of peptic ulcer treatment?

Answer 11

Reduce acid secretion
Augment protective mucosal barrier
Relieve pain
Promote ulcer healing
Prevent relapse and complications

Question 12

What treatment plans exist for peptic ulcers?

Answer 12

Remove irritants
Antibiotics
Acid suppressants
Mucosal protectants

Question 13

What acid suppressants are used?

Answer 13

Antacid’s
Proton pump inhibitors
H2 receptor antagonists

Question 14

What mucosal protectants can be used?

Answer 14

Sucralfate
Bismuth chelate
Misoprostol

Question 15

What do antacids do?

Answer 15

Provide symptomatic relief by raising gastric pH and reducing pepsin activity

Question 16

What are antacids normally made up of?

Answer 16

Most are salts of aluminium and magnesium often in combination
Cancel out laxative / constipation effects

Question 17

Describe sodium bicarbonate

Answer 17

Acts rapidly
Well absorbed
Can cause metabolic alkalosis
Sodium and water retention
Renal stone formation

Question 18

What proton pump inhibitors exist?

Answer 18

Omeprazole
Lansoprazole
Pantoprazole
Esomeprazole
Rabeprazole

Question 19

How are proton pump inhibitors absorbed?

Answer 19

Absorbed in the small intestine and then diffuse from the blood to parietal cells

Question 20

How are pro drug proton pump inhibitors activated?

Answer 20

By acid in parietal cells to sulfenamide, are trapped within the cell

Question 21

What do proton pump inhibitors do?

Answer 21

Inhibit basal and food stimulated acid secretion
Promote healing
Irreversible inhibitor with prolonged action
Requires synthesis of new pumps

Question 22

What are the mild side effects of proton pump inhibitors?

Answer 22

Diarrhoea
Nausea
Flatulence
Possible Headaches

Question 23

What are the more severe side effects of proton pump inhibitors?

Answer 23

Rebound effect of worsening symptoms after stopping the treatment
Can mask early cancer signs
(Bleeding, dysphagia, vomiting, weight loss)

Question 24

What are some of the drug interactions seen with proton pump inhibitors?

Answer 24

Weak cytochrome P450 (CYP) inhibitor
Reduced activation of clopidogrel
Reduced metabolism of warfarin

Question 25

Give some examples of H2 receptors antagonists

Answer 25

Cimetidine Ranitidine Famotidine

Question 26

How do H2 antagonist work?

Answer 26

Act as H2 receptors in gastric parietal cells Reduce basal and stimulated acid output (90%) Reduce volume of secretions and pepsin content

Question 27

What are the side effects of H2 antagonists?

Answer 27

Nausea Diarrhoea Headache Dizziness

Question 28

What symptoms can H2 antagonists cause in the elderly?

Answer 28

Confusion Depression

Question 29

What drug interactions are seen with H2 antagonists?

Answer 29

More than PPIs Cimetidine inhibits CYP dependent metabolism Potentially reacts with warfarin and phenytoin

Question 30

What is misoprostol?

Answer 30

An oral prostaglandin E2 analogue

Question 31

What does misoprostol do?

Answer 31

Stimulates mucus and bicarbonate Inhibits acid Prevents ulceration in long term NSAIDs users

Question 32

What are side effects seen when using misoprostol?

Answer 32

Diarrhoea Nausea Abdominal cramps Flatulence Vaginal bleeding

Question 33

Why is misoprostol more targeted to the older population?

Answer 33

Higher risk of abortion/ miscarriage Prostaglandin is very important within the reproductive tract Avoided in women of child bearing age

Question 34

How do mucosal protectants work?

Answer 34

Coats ulcers Absorbs pepsin Stimulates bicarbonate and mucus Toxic effect on H pylori Promotes healing

Question 35

What are the side effects of bismuth chelate?

Answer 35

Mucosal protectants can cause Blackened tongue and teeth Nausea Vomiting

Question 36

What is sucralfate?

Answer 36

A complex of aluminium hydroxide and sulfated sucrose

Question 37

How does sucralfate work?

Answer 37

Activated by acid Binds to proteins forming a protective layer on normal / damaged mucosa Stimulates mucus and bicarbonate Inhibits pepsin Reduces adherence of H pylori to mucosa Promotes healing

Question 38

What are the side effects when using sucralfate?

Answer 38

Constipation (due to aluminium) Dry mouth

Question 39

What is the triple therapy used to eradicate H pylori?

Answer 39

PPIs / H2 antagonist - raise gastric pH Increases H pylori’s susceptibility to antibiotics Clarithromyocin + amoxicillin Use metronidazole if allergic to penicillin

Question 40

What are the preventative treatments in place for ulcers?

Answer 40

High risk patients needing NSAIDS are also prescribed a PPI, misoprostol or H2 antagonist H pylori patients needing NSAID treatment are given eradication therapy

Question 41

Why are coxibs given?

Answer 41

To reduce the risk of gastrointestinal bleeding But increase the risk of cardiovascular event more than NSAIDs

Question 42

Which is better Cox 1 or Cox 2?

Answer 42

Cox 2 are selective inhibitors and minimise the side effects associated with Cox 1

Question 43

What are two examples of Cox 2 inhibitors?

Answer 43

Rofecoxib Celecoxib

Question 44

How are Cox 2 different?

Answer 44

Retain analgesic, anti inflammatory and antipyretic effects Reduce gastrointestinal toxicity but not renal toxicity

Question 45

What are the comparison points of aspirin vs coxibs?

Answer 45

Aspirin - fewer heart attacks, more bleeding events Coxibs - more heart attacks, fewer bleeding events

Question 46

What is GERD?

Answer 46

Gastric oesophageal reflux disease Heartburn Acid reflux causing inflammation of the oesophageal mucosa

Question 47

What are the treatments for GERD?

Answer 47

Antacids (gaviscon) PPIs / H2 antagonists Metocloperamide

Question 48

What is vonoprazan?

Answer 48

First in class reversible potassium competitive acid blocker More potent than lansoprazole

Question 49

When can vonoprazan be used?

Answer 49

GERD NSAID ulcers H pylori eradication with antacids

Question 50

Why would vonoprazan be favourable?

Answer 50

Prolonged duration of action Few mild side effects - mild gastrointestinal upset