PUD Flashcards
Peptic ulcer disease includes _________________ or __________________ ulceration, which is a breach in the epithelium of the mucosa
gastric
duodenal
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
upper abdominal pain
The main symptom of peptic ulcer disease is upper abdominal pain but other less common symptoms include…. (6)
- nausea
- indigestion
- heartburn
- loss of appetite
- weight loss
- a bloated feeling
What are the most common causes of PUD? (2)
- NSAIDs
2. H.pylori infection
In addition to NSAIDs and H.pylori, what other factors may contribute to the development of PUD? (3)
- Smoking
- Alcohol
- Stress
NSAIDs may have a(n) __________ effect if there is co-existent H. pylori infection, further increasing the risk of peptic ulceration
additive
The risk of upper gastro-intestinal side-effects varies between individual NSAIDs and is influenced by the ___________ and __________ of use.
dose
duration
*selective COX-2 inhibitors are less likely to cause PUD but are more likely to cause CV side effects
What are the complications of PUD? ( )
- Gastric outlet obstruction
- Potentially life-threatening GI perforation and
- Hemorrhage
Patients at high risk of developing GI complications with an NSAID include those with a history of … (9)
- Complicated peptic ulcer
OR those who have two or more of the following risk factors:
- Age over 65
- High dose NSAIDs
- Other drugs that increase the risk of GI adverse effects eg anticoagulants, corticosteroids, SSRIs
- Serious co-morbidity eg CVD, HTN, DM, renal or hepatic impairment
- Heavy smoker
- Excessive alcohol consumption
- Previous adverse reaction to NSAIDs
- Prolonged requirement for NSAIDs
Which drugs are associate with an increased risk of GI complications when co-prescribed with NSAIDs? (3)
- Anticoagulants
- Corticosteroids
- SSRIs
Which serious co-morbidities are associated with an increased risk of GI complications in patients who are taking NSAIDs? (5)
- CVD
- HTN
- DM
- Hepatic impairment
- Renal impairment
Which lifestyle measures are recommended for treating PUD? (9)
- Healthy diet
- Weight loss if obese
- Avoid trigger foods
- Eating smaller meals
- Eating the evening meal 3-4 hours before going to bed
- Raising the head of the bed
- Smoking cessation
- Reducing alcohol intake
- Managing stress, anxiety, and depression
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
dysphagia
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
acute gastrointestinal bleeding
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
55
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
unexplained weight loss
What is the initial managment of patients with PUD? (3)
- 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
- Antacids and/or alginates may be used for short-term symptom control, but long-term, continuous use is not recommended
- The patient should be tested for H. pylori infection
What is the management of a patient with PUD who is tested positive for H.pylori ad who has no history of NSAID use?
H.pylori eradication
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?
Prescribe a PPI or H2-receptor antagonist for 8 weeks, followed by H.pylori eradication treatment
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
8 weeks
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
proton pump inhibitor
H2-receptor antagonist
What is the management of patients with PUD who have tested negative for H.pylori and have no history of NSAID use?
Prescribe a PPI or H2-receptor antagonist for 4-8 weeks
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 ___________
4–8 weeks
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
proton pump inhibitor
histamine2-receptor antagonist (H2-receptor antagonist)
Is follow-up testing required after H.pylori eradication therapy?
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
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
a repeat endoscopy
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
6 months
paracetamol
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
cyclo-oxygenase (COX)-2 inhibitor
Gastro-protection with ____________ therapy should always be co-prescribed with NSAIDs. A(n) ______________ is the preferred choice for gastro-protection
acid suppression
proton pump inhibitor
*other options include a H2-receptor antagonist or misoprostol, but the side effects of misoprostol limit its use
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 ______________
H2-receptor antagonist
misoprostol (but the side effects of misoprostol limit its use)
If symptoms of PUD recur after initial treatment, how should patients be managed?
A PPI at the lowest dose possible to control symptoms; always on an ‘as-needed’ basis with patients managing their own symptoms
In cases where there are persistent symptoms or an unhealed ulcer, the patient’s _______________ should be checked and _____________ reinforced
adherence to initial management
lifestyle advice
In cases where there are persistent symptoms or an unheralded ulcer, which other causes should be considered? (6)
- Malignancy
- Failure to detect H.pylori
- Inadvertent NSAID use
- Other ulcer-inducing medications
- Rare causes such as Zollinger-Ellison syndrome or
- Crohn’s disease
Switching to an alternative acid suppression therapy, e.g. ________________ may be beneficial if the response to proton pump inhibitor therapy is inadequate
H2-receptor antagonists
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
refractory
recurrent
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
annual
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
step down
stopping
What are the first generation histamine antagonists? (5)
- Brompheniramine
- Chlorpheniramine
- Dimenhydrinate
- Diphenhydramine
- Doxylamine
What are the second generation antihistamines? (3)
- Loratidine
- Cetirizine
- Fexofenadine
(The fox, satyr, and rat)
What is the main advantage of second generation antihistamines over first generation?
Less sedation
Also fewer side effects and interactions in general
All antihistamines should be prescribed with caution in patients with signs and symptoms of ____________
Gastric cancer (might mask symptoms and delay treatment)
What are the common general side effects shared by all antihistamines? (6)
- Diarrhea, constipation
- Dizziness
- Fatigue
- Headache
- Myalgia
- Skin reactions
What are the rare but dangerous side effects associated with antihistamines? (5)
- Bone marrow suppression and agranulocytosis
- AV block
- Acute interstitial nephritis
- Dyskinesia
- Acute pancreatitis
Are antihistamines safe to use in pregnancy and breastfeeding?
Avoid unless essential during pregnancy
Significant amount in breast milk but not known to be harmful
Are antihistamines safe to use in renal and/or hepatic impairment?
Decrease dose in renal impairment
Children under 6 years should not be given over-the-counter cough and cold medicines containing __________________.
chlorphenamine (chlorpheniramine), a first generation antihistamine
First generation antihistamines should be prescribed with caution in which patients? (5)
- Epilepsy
- Prostatic hypertrophy
- Pyloroduodenal obstruction
- Susceptibility to angle closure glaucoma
- Urinary retention
(Due to antimuscarinic side effects of first gen antihistamines)
Common or very common side effects of first generation antihistamines include… (8)
- Impaired concentration
- Abnormal coordination
- Dizziness
- Blurred vision
- Dry mouth
- Fatigue
- Headache
- Nausea
(Think sedation and antimuscarinic side effects)
_______________ may be a side effect of antihistamines administered parenterally
Confusional psychosis
Use of antihistamines in the latter part of the third trimester may cause adverse effects in neonates such as _____________, _____________, and ______________
irritability
paradoxical excitability
tremor
Are first generation antihistamines safe to prescribe in patients with hepatic and/or renal impairment?
Use caution in hepatic impairment
What patient and carer advice should be given regarding use of first generation antihistamines? (2)
Drowsiness may affect ability to perform skilled tasks eg driving, cycling
Sedating effects enhanced by alcohol
