PUD

Question 1

Peptic ulcer disease includes _________________ or __________________ ulceration, which is a breach in the epithelium of the mucosa

Answer 1

gastric

duodenal

Question 2

The main symptom of peptic ulcer disease is _________________ but other less common symptoms include nausea, indigestion, heartburn, loss of appetite, weight loss and a bloated feeling

Answer 2

upper abdominal pain

Question 3

The main symptom of peptic ulcer disease is upper abdominal pain but other less common symptoms include…. (6)

Answer 3

1. nausea
2. indigestion
3. heartburn
4. loss of appetite
5. weight loss
6. a bloated feeling

Question 4

What are the most common causes of PUD? (2)

Answer 4

1. NSAIDs

2. H.pylori infection

Question 5

In addition to NSAIDs and H.pylori, what other factors may contribute to the development of PUD? (3)

Answer 5

1. Smoking
2. Alcohol
3. Stress

Question 6

NSAIDs may have a(n) __________ effect if there is co-existent H. pylori infection, further increasing the risk of peptic ulceration

Answer 6

additive

Question 7

The risk of upper gastro-intestinal side-effects varies between individual NSAIDs and is influenced by the ___________ and __________ of use.

Answer 7

dose

duration

*selective COX-2 inhibitors are less likely to cause PUD but are more likely to cause CV side effects

Question 8

What are the complications of PUD? ( )

Answer 8

1. Gastric outlet obstruction
2. Potentially life-threatening GI perforation and
3. Hemorrhage

Question 9

Patients at high risk of developing GI complications with an NSAID include those with a history of … (9)

Answer 9

1. Complicated peptic ulcer

OR those who have two or more of the following risk factors:

2. Age over 65
3. High dose NSAIDs
4. Other drugs that increase the risk of GI adverse effects eg anticoagulants, corticosteroids, SSRIs
5. Serious co-morbidity eg CVD, HTN, DM, renal or hepatic impairment
6. Heavy smoker
7. Excessive alcohol consumption
8. Previous adverse reaction to NSAIDs
9. Prolonged requirement for NSAIDs

Question 10

Which drugs are associate with an increased risk of GI complications when co-prescribed with NSAIDs? (3)

Answer 10

1. Anticoagulants
2. Corticosteroids
3. SSRIs

Question 11

Which serious co-morbidities are associated with an increased risk of GI complications in patients who are taking NSAIDs? (5)

Answer 11

1. CVD
2. HTN
3. DM
4. Hepatic impairment
5. Renal impairment

Question 12

Which lifestyle measures are recommended for treating PUD? (9)

Answer 12

1. Healthy diet
2. Weight loss if obese
3. Avoid trigger foods
4. Eating smaller meals
5. Eating the evening meal 3-4 hours before going to bed
6. Raising the head of the bed
7. Smoking cessation
8. Reducing alcohol intake
9. Managing stress, anxiety, and depression

Question 13

Urgent endoscopic investigation is required for patients with ______________, significant acute gastrointestinal bleeding, or in those aged 55 years and over with unexplained weight loss and symptoms of upper abdominal pain, reflux or dyspepsia

Answer 13

dysphagia

Question 14

Urgent endoscopic investigation is required for patients with dysphagia, significant _________________, or in those aged 55 years and over with unexplained weight loss and symptoms of upper abdominal pain, reflux or dyspepsia

Answer 14

acute gastrointestinal bleeding

Question 15

Urgent endoscopic investigation is required for patients with dysphagia, significant acute gastrointestinal bleeding, or in those aged __________ years and over with unexplained weight loss and symptoms of upper abdominal pain, reflux or dyspepsia

Answer 15

55

Question 16

Urgent endoscopic investigation is required for patients with dysphagia, significant acute gastrointestinal bleeding, or in those aged 55 years and over with _____________ and symptoms of upper abdominal pain, reflux or dyspepsia

Answer 16

unexplained weight loss

Question 17

What is the initial managment of patients with PUD? (3)

Answer 17

1. Drugs that induce peptic ulcers, such as NSAIDs, aspirin, bisphosphonates, immunosuppressive agents (e.g. corticosteroids), potassium chloride, selective serotonin reuptake inhibitors (SSRIs) and recreational drugs such as crack cocaine should be reviewed and stopped, if clinically appropriate
2. Antacids and/or alginates may be used for short-term symptom control, but long-term, continuous use is not recommended
3. The patient should be tested for H. pylori infection

Question 18

What is the management of a patient with PUD who is tested positive for H.pylori ad who has no history of NSAID use?

Answer 18

H.pylori eradication

Question 19

What is the management of a patient with PUD who has tested positive for H.pylori and also has a strong history of NSAID use?

Answer 19

Prescribe a PPI or H2-receptor antagonist for 8 weeks, followed by H.pylori eradication treatment

Question 20

If the ulcer is associated with NSAID use, a proton pump inhibitor or H2-receptor antagonist should be used for _____________, followed by Helicobacter pylori infection eradication treatment if the patient has tested positive for H. pylori

Answer 20

8 weeks

Question 21

If the ulcer is associated with NSAID use, a(n) ________________ or _________________ should be used for 8 weeks, followed by Helicobacter pylori infection eradication treatment if the patient has tested positive for H. pylori

Answer 21

proton pump inhibitor

H2-receptor antagonist

Question 22

What is the management of patients with PUD who have tested negative for H.pylori and have no history of NSAID use?

Answer 22

Prescribe a PPI or H2-receptor antagonist for 4-8 weeks

Question 23

In patients who have tested negative for H. pylori and have no history of NSAID use, a proton pump inhibitor or histamine2-receptor antagonist (H2-receptor antagonist) should be used for ___________

Answer 23

4–8 weeks

Question 24

In patients who have tested negative for H. pylori and have no history of NSAID use, a(n) _____________ or ____________ should be used for 4–8 weeks

Answer 24

proton pump inhibitor

histamine2-receptor antagonist (H2-receptor antagonist)

Question 25

Is follow-up testing required after H.pylori eradication therapy?

Answer 25

Yes, 6-8 weeks after starting eradication therapy * Patients with a gastric ulcer who tested positive for H. pylori should also have a repeat endoscopy 6–8 weeks after treatment to confirm ulcer healing, depending on the size of the lesion

Question 26

Patients with a gastric ulcer who tested positive for H. pylori should also have a _______________ 6–8 weeks after treatment to confirm ulcer healing, depending on the size of the lesion

Answer 26

a repeat endoscopy

Question 27

If the peptic ulcer is healed and the patient is to continue taking NSAIDs, the potential harm from NSAID treatment should be discussed. The need for NSAIDs should be reviewed at least every _______________, and use on a limited, 'as-needed' basis trialled. Consider reducing the dose, substituting the NSAID with _______________, or use of an alternative analgesic or low dose ibuprofen

Answer 27

6 months paracetamol

Question 28

In patients with previous ulceration, for whom NSAID continuation is necessary, or those at high risk of gastro-intestinal side effects, consider a(n) ________________ instead of a standard NSAID

Answer 28

cyclo-oxygenase (COX)-2 inhibitor

Question 29

Gastro-protection with ____________ therapy should always be co-prescribed with NSAIDs. A(n) ______________ is the preferred choice for gastro-protection

Answer 29

acid suppression proton pump inhibitor *other options include a H2-receptor antagonist or misoprostol, but the side effects of misoprostol limit its use

Question 30

Gastro-protection with acid suppression therapy should always be co-prescribed. A proton pump inhibitor is the preferred choice for gastro-protection; other options include a(n) ______________ or ______________

Answer 30

H2-receptor antagonist misoprostol (but the side effects of misoprostol limit its use)

Question 31

If symptoms of PUD recur after initial treatment, how should patients be managed?

Answer 31

A PPI at the lowest dose possible to control symptoms; always on an ‘as-needed’ basis with patients managing their own symptoms

Question 32

In cases where there are persistent symptoms or an unhealed ulcer, the patient's _______________ should be checked and _____________ reinforced

Answer 32

adherence to initial management lifestyle advice

Question 33

In cases where there are persistent symptoms or an unheralded ulcer, which other causes should be considered? (6)

Answer 33

1. Malignancy 2. Failure to detect H.pylori 3. Inadvertent NSAID use 4. Other ulcer-inducing medications 5. Rare causes such as Zollinger-Ellison syndrome or 6. Crohn’s disease

Question 34

Switching to an alternative acid suppression therapy, e.g. ________________ may be beneficial if the response to proton pump inhibitor therapy is inadequate

Answer 34

H2-receptor antagonists

Question 35

Referral to a specialist for investigations and management should occur in ______________ or ______________ peptic ulcer cases with gastro-oesophageal symptoms that are unexplained, or non-responsive to treatment

Answer 35

refractory recurrent

Question 36

Patients with peptic ulcer disease who are on long-term treatment should receive a(n) ______________ review of their symptoms and treatment. A step down approach, or stopping treatment, should be encouraged if possible and clinically appropriate

Answer 36

annual

Question 37

Patients with peptic ulcer disease who are on long-term treatment should receive an annual review of their symptoms and treatment. A _________________ approach, or _____________ treatment, should be encouraged if possible and clinically appropriate

Answer 37

step down stopping

Question 38

What are the first generation histamine antagonists? (5)

Answer 38

1. Brompheniramine 2. Chlorpheniramine 3. Dimenhydrinate 4. Diphenhydramine 5. Doxylamine

Question 39

What are the second generation antihistamines? (3)

Answer 39

1. Loratidine 2. Cetirizine 3. Fexofenadine (The fox, satyr, and rat)

Question 40

What is the main advantage of second generation antihistamines over first generation?

Answer 40

Less sedation | Also fewer side effects and interactions in general

Question 41

All antihistamines should be prescribed with caution in patients with signs and symptoms of ____________

Answer 41

Gastric cancer (might mask symptoms and delay treatment)

Question 42

What are the common general side effects shared by all antihistamines? (6)

Answer 42

1. Diarrhea, constipation 2. Dizziness 3. Fatigue 4. Headache 5. Myalgia 6. Skin reactions

Question 43

What are the rare but dangerous side effects associated with antihistamines? (5)

Answer 43

1. Bone marrow suppression and agranulocytosis 2. AV block 3. Acute interstitial nephritis 4. Dyskinesia 5. Acute pancreatitis

Question 44

Are antihistamines safe to use in pregnancy and breastfeeding?

Answer 44

Avoid unless essential during pregnancy Significant amount in breast milk but not known to be harmful

Question 45

Are antihistamines safe to use in renal and/or hepatic impairment?

Answer 45

Decrease dose in renal impairment

Question 46

Children under 6 years should not be given over-the-counter cough and cold medicines containing __________________.

Answer 46

chlorphenamine (chlorpheniramine), a first generation antihistamine

Question 47

First generation antihistamines should be prescribed with caution in which patients? (5)

Answer 47

1. Epilepsy 2. Prostatic hypertrophy 3. Pyloroduodenal obstruction 4. Susceptibility to angle closure glaucoma 5. Urinary retention (Due to antimuscarinic side effects of first gen antihistamines)

Question 48

Common or very common side effects of first generation antihistamines include… (8)

Answer 48

1. Impaired concentration 2. Abnormal coordination 3. Dizziness 4. Blurred vision 5. Dry mouth 6. Fatigue 7. Headache 8. Nausea (Think sedation and antimuscarinic side effects)

Question 49

_______________ may be a side effect of antihistamines administered parenterally

Answer 49

Confusional psychosis

Question 50

Use of antihistamines in the latter part of the third trimester may cause adverse effects in neonates such as _____________, _____________, and ______________

Answer 50

irritability paradoxical excitability tremor

Question 51

Are first generation antihistamines safe to prescribe in patients with hepatic and/or renal impairment?

Answer 51

Use caution in hepatic impairment

Question 52

What patient and carer advice should be given regarding use of first generation antihistamines? (2)

Answer 52

Drowsiness may affect ability to perform skilled tasks eg driving, cycling Sedating effects enhanced by alcohol