PUD

Question 1

what is PUD

Answer 1

PUD is a defect in the gastric mucosa or duodenal mucosal wall that extends through the muscularis mucosal wall into the deep layers of the submucosa

Question 2

PUD is a significant cause of ________ and is associated with_______________.

Answer 2

morbidity

high health care costs.

Question 3

what are the causes of PUD

Answer 3

H.pylori infections
NSAIDS use
stress related mucosal damage

Question 4

Global prevalence of H. pylori infection

Answer 4

50%

Question 5

factors that affect the prevalence of H.pylori infection

Answer 5

age, ethnicity, sex, geography, socioeconomic status and geographical location

Question 6

how is the infection transmitted

Answer 6

through fecal contaminated water-food

Question 7

what are the complications of untreated or undiagnosed H.pylori infection

Answer 7

peptic ulcer disease and gastric cancer

Question 8

what does chronic NSAIDs use cause

Answer 8

nausea and dyspepsia in nearly half of the users

Question 9

peptic ulceration occurs in ____% of patients who chronically use NSAIDS with ____% who develop ______ and ________ in those who develop an ulcer

Answer 9

30%
1.5%
GI bleeding and perforation

Question 10

Risk factors for ulcers & GI complications related to NSAIDs use

Answer 10

Age older than 60 years
Multiple NSAID use (e.g., low-dose aspirin plus another NSAID)
Duration of NSAID use (> 1 month)
High-dose NSAID use
Concomitant use of corticosteroid, SSRI or anticoagulant
Previous PUD or PUD complications (bleeding / perforation)
Cardiovascular disease and other comorbid conditions
Smoking
Alcohol ingestion

Question 11

who are affected by stress induced ulcers and why

Answer 11

critically ill patients who have a mucosal defect by gastric mucosal ischemia or intraluminal acid

Question 12

the ulcers are non superficial. true or false

Answer 12

false. they are superficial but may penetrate into the submucosa and cause significant GI bleeding

Question 13

Physiologically stressful situations that lead to Stress ulcer include:

Answer 13

Sepsis
Organ failure
Prolonged mechanical ventilation
Thermal injury (burns)
Surgery.

Question 14

what is zollinger ellison syndrome caused by

Answer 14

gastrin secreting tumor [gastrinoma]

the hypersecretion of gasric acid leads to diarrhea and malabsorption

Question 15

Ulcers tend to be ________ and have a high risk of _____________.

Answer 15

numerous

perforation & bleeding.

Question 16

The harmful effects of smoking on the gastric mucosa:

Answer 16

Increased pepsin secretion
Duodeno-gastric reflux of bile salts
Elevated levels of free radicals
Reduced prostaglandin-2 (PG2) production

Question 17

decreased mucus and increased bicarbonate secretion is a side effect of smoking. true or false

Answer 17

false. decreased mucus and also decreased bicarbonate secretion

Question 18

describe the location of each

a. H.pylori related ulcers
b. Nsaids induced ulcers

Answer 18

a. duodenal ulcer

b. gastric ulcer

Question 19

how do ulcers form (pathophysiology)

Answer 19

ulcers form due to disruption of balance of factors that breakdown food eg. gastric acid and pepsin and factors that promote mucosal defense and repair eg. mucus secretion, bicarbonate secretion and prostaglandins

Question 20

symptoms of PUD range from?

Answer 20

mild epigastric pain to life threatening conditions

Question 21

are duodenal ulcers relieved by food. when is their onset

Answer 21

yes relieved by food

onset - 1 to 3 hours after meals or at night

Question 22

are gastric ulcers relieved by food

Answer 22

no, aggravated by food

Question 23

how are ulcers documented in diagnosis

Answer 23

by radiologic or endologic procedures

Question 24

when is testing for H. pylori done

Answer 24

initiated in patients with active PUD, history of PUD and gastric mucosa associated lymphoid tissue lymphoma

Diagnostic tests for H. pylori presence can be endoscopic or non-endoscopic.

Question 25

what does endoscopic diagnosis involve

Answer 25

Endoscopic diagnosis involves extraction of gastric tissue samples that are subsequently tested for H. pylori.

Question 26

what is the standard identification method. what are the others?

Answer 26

histology is standard indentification method culture, PCR and rapid urease test can also be used

Question 27

what are the non endoscopic identification procedures what is their advantage which one is 1st line. and why? how does it work/

Answer 27

urea breath test, serologic testing, and stool antigen assay. These tests are less invasive and less expensive than endoscopy. The urea breath test is 1st line because of its high sensitivity and specificity and short time needed to perform. The urea breath test can also be used to confirm eradication of H. pylori The test is based on the ability of the H. Pylori to convert urea to ammonia

Question 28

what are the non pharmacology goals in PUD

Answer 28

reduce psychological stress avoid smoking or alcohol consumption avoid NSAIDs and aspirin

Question 29

what is the ttt for patients with RA who need NSAIDs chronically

Answer 29

ulcer prophylaxis ttt and/or paracetamol if possible

Question 30

when is surgical intervention initiated

Answer 30

for complicated and refractory cases

Question 31

what is the ttt of acute GI bleeding

Answer 31

contact thermal therapy, mechanical therapy using clips and epinephrine injection followed by contact therapy and/or mechanical therapy

Question 32

in H.pylori induced ulcers are acid suppressants used? why?

Answer 32

acid suppressants are not used as they increase ulcers and ulcer related complications

Question 33

in h pylori induced ulcers which regimen is more effective triple therapy or quadruple therapy

Answer 33

triple therapy

Question 34

what is regimen 1 and regimen 2 in h pylori induced ulcers

Answer 34

``` regimen 1 PPI - omeprazole or lansoprazole clarithromycin [klacid] 500 mg bid amoxicllin [amoxil] 1000mg bid for 1 wk or some recommed 10-14 days continue for 1 month with PPis ``` ``` regimen 2 bismuth subsalicylate 524mg qid metronidazole [flagyl] 250mg qid tetracycline [tetradar] 500mg qid H2RA antagonist [cimetidine or ranitidine] (some replace w PPi) for 2 wks continue with H2RA for 1 month ```

Question 35

what are drugs are used to prevent NSAID related ulcers

Answer 35

DC and alternative is paracetamol | if can not Dc then PPis, H2RAs and sucralfate prevent ulcers and promote healing

Question 36

why are ppis preferred

Answer 36

strongest acid suppression, faster relief from symptoms and prevent recurrences at standard doses for gastric and duodenal ulcers as effective as misoprostol

Question 37

at standard doses for gastric and duodenal ulcers ppis are not as effective as misoprostol. true or false

Answer 37

false

Question 38

PPis are better tolerated than misoprotol. true or false.

Answer 38

true

Question 39

what are the goals of therapy in stress ulcers

Answer 39

hemodynamic stability for increased mesentric perfusion and pharmaco GI acid suppression

Question 40

stress ulcer prophylaxis is used only in?

Answer 40

ICU patients

Question 41

weigh risk vs benefits of ppis in _________

Answer 41

low risk patients

Question 42

what are the DOC in stress ulcers and 2nd lines in some patients

Answer 42

DOC - ppis and H2RAs | antacids and sucralfate accepted in some patients.

Question 43

brief indications of stress ulcers (10) points

Answer 43

- mechanicalventilation longer than 48 hours. coagulopathy. Hepatic failure - Gi ulceration or bleeding within 1 yr - head trauma, glassgow coma less than or equal to 10 - thermal injuries > 30% BSF - partial hepatectomy - transplant pt ICU preoperatively 1 spinal cord injuries -2 of following, sepsis, ICU stay greater than 1 wk occult bleeding less than or equal to 6 days, corticosteroids 250mg/day or more of hydrocortisone or equivalent

Question 44

describe the long term maintenance of ulcers

Answer 44

PPis and H2RAs in pts w severe complications 2ndry to PUD - gastric outlet obstruction - chronic use of NSAIDs or high dose coticosteroids w high risk of bleeding.

Question 45

name first line 3 drugs good to excellent

Answer 45

- clarithromycin + metro + omeprazole | - clarithromycin + amoxil + lansoprazole

Question 46

name helidac (good)

Answer 46

- bismuth subsalicylate + metro + tetra .... + ranitidine (BTRM)

Question 47

name pylera [good to excellent]

Answer 47

- bismuth subcitrate potassium + metro + tetra ... 3 caps bid + omeprazole (tomb)

Question 48

concomitant therapy

Answer 48

eso + amoxil + clarithromycin + metro ( cema)

Question 49

sequential therapy

Answer 49

Amoxil + eso (1-5days) .. Amoxil + eso + metro (6-10days)