PUD

Question 1

Signs and Symptoms

Answer 1

Alarm
-Bleeding
-Unexplained wt loss
-Dysphagia
-Odynophagia
-Vomiting

Common
-Epi pain, abd pain
-Discomfort: burning, cramp, fullness
-Heartburn, belching, bloating

Question 2

3 causes = 3 most common

Answer 2

1. H. pylori infection
2. NSAID use
3. Stress

Question 3

H. Pylori testing – who do you test?

Answer 3

All patients with:
* Active/symptomatic PUD
* PMH PUD
* MALT lymphoma
* History endoscopic resection of early gastric cancer

Testing is NOT recommended in patients:
* GERD with no PMH PUD

Question 4

H. Pylori Cure

Answer 4

• Cure defined as no H.pylori detected 4 weeks post therapy and 1-2 weeks after PPI is stopped
• Relief of ulcer-associated pain, promote ulcer healing, prevent reoccurance, and reduce complications of PUD

Question 5

Non-pharmacologic Considerations

Answer 5

-Avoid tobacco/smoking
-Diet (avoid trigger foods, laying down after eating, limit alc/caf)
-Probiotics? Lactobacillus/bifidobacterium
-Weight loss
-Elevate head of bed 6-8 in (GERD pillow)

Question 6

1st line therapy H.pylori PUD

Answer 6

1. Quad: Bismuth, Tetra, Metro, PPI (MT PB)
2. Clarithromycin, Amox, Metro, PPI (PACM)
3. Clari, Amox, PPI (PAC)
4. Clari, Metro, PPI (PMC)
5. Levo, Amox, PPI (PAL)

Question 7

Penicillin Allergy? and NO Macrolide exp/res

Answer 7

-Bismuth quadruple (MTPB)
-Clarithromycin triple w/metro (PMC)

Question 8

Penicillin Allergy AND Macro exp/res

Answer 8

-Bismuth quadruple

Question 9

Macrolide Exp/Res

Answer 9

-Bismuth quadruple
-Levofloxacin triple
-Levofoxacin sequential

Question 10

Clarithromycin Dosing

Answer 10

500 mg BID

Question 11

Bismuth Dosing

Answer 11

525 mg QID

Question 12

Metronidazole frequency varies

Answer 12

• BID with concomitant therapy
• TID – Clarithromycin ‘triple’ regimen
• QID – bismuth ‘quadruple’ therapy

Question 13

Monitoring/Follow up

Answer 13

-Pain, weight
-Compliance
-AEs for PPI/ABX (NVD)

Test H.pylori 4 wk after completion, 1-2 wk after last PPI dose

Question 14

AEs bismuth quadruple

Answer 14

• Bismuth subsalicylate – darkening stool, tongue color changes
• Tetracycline – photosensitivity
• Metronidazole – disulfiram-rxn with etOH, taste disturbance

Question 15

Patient Education

Answer 15

-Complete 10-14 day therapy duration
-Avoid PPI & H2RA OTC products
-Avoid tobacco/smoking
-AEs
-Role of probiotics

Question 16

Salvage Therapy

Answer 16

Avoid antibiotics that were previously taken for 1st line

If received 1st line bismuth quadruple, then
* Levofloxacin triple (PAL)
*Avoid clarithromycin triple w/amoxicillin or w/metronidazole

If received a 1st line regimen containing clarithromycin, options are
* Bismuth quadruple therapy
* Levofloxacin triple (PAL)

Question 17

Current etOH use/misuse/abuse?

Answer 17

-Avoid metronidazole containing regimens (disulfiram-like rxn)

-Options: levofloxacin triple

Question 18

If confirmation of an active ulcer (via endoscopy) and the patient is H.pylori NEGATIVE…

Answer 18

• PPI or H2RA or sucralfate x 8 weeks
• May need to stop NSAID therapy

CV disease prevention?
* Continue ASA 81 mg/day plus PPI or misoprostol