PUD

Question 1

Causes of PUD

Answer 1

• h. pylori
• medications such as NSAIDs, SAS and glucocorticoids
• more common in men
• duodenal ulcers between ages 30-55
• gastric ulcers between ages 55-65
• alcohol and dietary factors DO NOT seems to cause ulcers

Question 2

Signs and Symptoms PUD

Answer 2

Duodenal: relief with eating
Gastric: pain worsens with eating

Question 3

Physical findings of PUD

Answer 3

• mild epigastric tenderness
• Gi bleeding (20%): Melena, hematemesis
• Perforation (5-10%): severe epigastric pain, board like and, rigidity-rare

Question 4

Labs and diagnostics of PUD

Answer 4

• may see anemia on cbc
• consider endoscopy after 2-8 weeks tx
• H. Pylori testing

Question 5

Outpatient management PUD with PPI or H2 receptor antagonist

Answer 5

H2 receptor antagonists:
-tagamet 800mg
Ranitidine (zantac)
-Famotidine (pepcid)
-Axid
start with these and give at night
more expensive than PPI

PPI:
-Lansoprazole etc
if H2 blockers don’t work then work to PPI

Mucosal protective agent: given 2 hours apart from other meds
-sucralfate (requires acidic environment-avoid antacids and H2 blockers)
is a/w decreases in nonsocomial pna

Bismuth (pepto)

• direct antibacterial action against H, pylori
• promotes prostaglandic production/stimulates gastric bicarbonate

Misoprostol 4x daily with food
-used as prophylaxis against NSAID induced ulcers
-stimulates mucous and bicarb production
-may stimulate uterine contraction**
-PPI in pts who cannot discontinue NSAIDs
H2 blockers, sucralfate, and antacids do not prevent NSAID-induced ulcers

Antacids (mylanta, maalox, MOM) do not reduce the amount of gastric acidity

Question 6

H. Pylori eradication therapy

Answer 6

must use combo therapy

• resistance develops quickly to flagyl and clarithromycin
• does not develop quickly to amoxicillin or tetracycline

Combo options: 2 abx and a PPI or bismuth
-flagyl 500 bid with omeprazole 20 bid and clarithromycin 500 bid

• amox 1 g daily, ompeprazole 20 bid and clarith 500 bid
• flagyl 500 bid, omeprazole 20 bid and amox 1 g bid for 7-14 days

after abx therapy continue PPI then switch to H2

Question 7

Bismuth regimens for H. Pylori

Answer 7

four times daily and have more side effects

-bismuth 2 tabs, flagyl 250 and tetracycline 500

or the above regimen plus omeprazole 20 mg bid x 7 days

Question 8

Inpatient management of PUD

Answer 8

• cbc, pt/ptt, bmp
• endoscopy
• bladder catheter
• npo,ng tube
• upright decub films show free air in 75% of cases
• monitor abd
• IV H2 blockers
• if coagulopathy present give FFP
• if thrombocytopenia < 50,000 transfuse platelets
• GI eval

Question 9

GERD. what is it?

Answer 9

a disorder characterized by the back flow (reflux) of acidic gastric contents into the esophagus.

• imcompetent lower esophageal sphincter
• delayed gastric emptying

Question 10

S & S GERD

Answer 10

• retrosternal burning
• bitter taste in mouth
• belching, dysphagia
• excessive salvation
• frequently occurs at night or in recumbent position
• may be relieved by sitting u p, antacids, water or food

Question 11

Diagnostics of GERD

Answer 11

referal for esophagogastroduodenoscopy (EGD): R/O cancer, Barrett’s esophagus, PUD etc

Question 12

Management GERD non pharmacological

Answer 12

-elevated HOB
-avoid alc and caffeine, spices, peppermint
-stop smoking
weight reduction

Question 13

Management GERD pharmacological

Answer 13

• antacids PRN
• H2 blockers (tidiness) in high doses at night or decided twice daily
• PPI if H2 blockers ineffective
• GI surgical consult PRN