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PUD Flashcards

1
Q

What is PUD?

A

ulceration of the mucosa anywhere in the GI tract exposed to acid and pepsin

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2
Q

Which PUD form is most common?

A

Duodenal > Gastric

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3
Q

What is PUD caused by?

A
  1. Helicobacter pylori (HP)
  2. Chronic NSAID use
  3. Stress-related mucosal damage
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4
Q

Does smoking improve or worsen PUD?

A

worsen

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5
Q

What is the mechanism of stress-related mucosal damage?

A
  1. decreased mucosal defense mechanisms
  2. emotional stress –> increased smoking/ NSAID use –> increased risk of PUD
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6
Q

What is the pathogenesis of PUD?

A

Imbalance between aggressive factors and mechanisms that maintain mucosal integrity

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7
Q

What is the most common cause of duodenal (~95%) and gastric ulcers (~80%)?

A

H. pylori

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8
Q

How is H.pylori spread?

A
  1. fecal to oral route
  2. oral to oral route
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9
Q

What are possible mechanisms for H.pylori induced mucosal damage?

A
  1. catalyzes urea–> ammonia–> erodes mucosal barrier and epithelial damage
  2. production of cytotoxins
  3. production of mucolytic enzymes
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10
Q

How likely are ulcers caused by chronic NSAID use?

A

Duodenal (2-5%) and gastric (10-20%)

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11
Q

What are mechanisms for NSAID induced ulcers?

A
  1. inhibit cyclooxygenase activity–> decrease prostaglandin production
  2. decrease gastric and mucosal blood flow
  3. decreased mucus and bicarbonate secretion
  4. decreased cellular replication and repair
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12
Q

Who is more likely to experience major complications due to NSAIDs?

A
  1. > 60 y/o
  2. Hx of PUD
  3. High dose/ multiple NSAIDs or low dose ASA daily,
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13
Q

What medications administered with NSAIDs will increase risk of PUD?

A
  1. corticosteroids
  2. anticoagulants
  3. oral bisphosphonates
  4. antiplatelet agents
  5. SSRIs
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14
Q

What NSAID is the most ulcerogenic?

A

Aspirin

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15
Q

What is the first presentation of NSAID-induced ulcers?

A

bleeding/ perforation

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16
Q

What are common presentations of gastric ulcers?

A
  1. pain is not predictable
  2. food can cause pain
  3. weight loss
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17
Q

What are common presentations of gastric ulcers?

A
  1. pain more likely to follow consistent pattern
  2. food often eases pain and returns in 1-3 hours
  3. noctural epigastric pain
  4. nonspecific dyspepsia
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18
Q

What are the major complications of PUD?

A
  1. bleeding
  2. perforation
  3. death from acute bleeding
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19
Q

What lab tests are used to determine H.pylori-induced ulcers?

A
  1. Rapid Urease Test (CLO test)
  2. serologic antibody test
  3. Urea Breath Test (UBT)
  4. Fecal Antigen Test (FAT)
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20
Q

How is the Rapid Urease test done?

A

Mucosal biopsy–> urea rich medium with pH sensitive dye–> HP urease will produce NH3, increase the pH and cause a color change

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21
Q

How does a serologic test determine HP infection?

A

Detects IgG to HP in serum

22
Q

What are problems with the serologic test?

A

Can’t distinguish active infection from past exposure because antibodies persist for up to 5 years

23
Q

How does the Urea Breath Test (UBT) work?

A

Patient ingests molecule with C 13/14–> H. pylori urease produces CO2 13/14–> CO2 13/14 is in blood and can be detected in breath

24
Q

How does the Fecal Antigen Test (FAT) work?

A

polyclonal antibody test detects presence of HP in the stool

25
Q

Patients recently taking antibiotics & bismuth compounds (~4 weeks), or anti-secratory agents (~2weeks) can cause false positives in what test?

A

UBT

26
Q

What tests are used for initial screening for infection?

A

serologic, UBT, FAT

27
Q

What tests are used to determine eradication?

A

UBT and FAT

28
Q

How long after treatment is completed do you need to wait before confirming eradication?

A

4 weeks

29
Q

What are 1st line therapies for HP eradication?

A
  1. Bismuth-based quadruple therapy
  2. Standard Triple Therapy
  3. Concomitant therapy
30
Q

What is used for Standard Triple Therapy?

A

Amoxicillin + Clarithromycin + PPI
Penicillin allergy: Metronidazole

31
Q

When is Standard Triple Therapy 1st line?

A

Clarithromycin resistance rates <15% and patient has NEVER taken a macrolide antibiotic

32
Q

What is used for Bismuth-based Quadruple Therapy?

A

Tetracycline + Metronidazole + Bismuth subsalicylate + PPI

33
Q

What can be used for Bismuth-based Quadruple therapy if there is a salicylate allergy?

A

Bismuth subcitrate (Pylera)

34
Q

When is Bismuth-based quadruple therapy
1st line?

A

Clarithromycin resistance rates > 15% and/ or patient has taken a macrolide antibiotic

35
Q

What agents are used for concomitant therapy?

A

Clarithromycin + Amoxicillin + Metronidazole/ Tinidazole + PPI

36
Q

What are 2nd line “salvage therapies”?

A
  1. Levofloxacin-based Triple Therapy
  2. Rifabutin-based Triple Therapy
37
Q

What agents are used for Levofloxacin-based Triple Therapy?

A

Amoxicillin + Levofloxacin + PPI

38
Q

What agents are used for Rifabutin-based Triple Therapy?

A

Omeprazole + Amoxicillin + Rifabutin

39
Q

When would Rifabutin- based triple therapy be used?

A

persistent HP infection; preferred if patient received clarithromycin therapy prior

40
Q

How long after eradication is a PPI continued for?

A

2 weeks

41
Q

What is used to treat H. pylori negative ulcers?

A

H2 antagonists
Sucralfate
PPI

42
Q

How long does it take for H2 antagonists and Sucralfate to heal ulcers?

A

6-8 weeks

43
Q

How long does it take for PPIs to heal ulcers?

A

4 weeks

44
Q

Which kind of ulcers are more difficult to treat?

A

gastric ulcers

45
Q

What are treatment options for NSAID induced ulcers?

A
  1. D/c NSAID
  2. Stardard healing dose of H2RA, sucralfate, or PPI
46
Q

What are treatment options for NSAID induced ulcers when NSAIDs cannot be discontinued?

A
  1. Decrease dose
  2. APAP, non-aceylated agent, selective COX-2 inhibitor
  3. Use PPI
47
Q

What patients should receive long term maintenance therapy with a PPI or H2RA?

A
  1. HP positive ulcers with failed eradication attempts
  2. refractory ulcers
  3. heavy smokers
48
Q

What agents are best for chronic NSAID users to prevent recurrence of ulcers?

A
  1. PPIs
  2. Misoprostol
49
Q

What are important counseling points for patients with PUD?

A
  1. communicate cause
  2. address risk factors
  3. rationale of multi-drug regimens and importance of adherence + completion of therapy
  4. make patient aware of GI bleeding
50
Q

What are signs of GI bleeding?

A
  1. tarry stools
  2. abdominal pain
  3. vomiting with blood

GI (23 decks)

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