PUD Case Flashcards
major independent lifestyle rf for symptomatic and asymptomatic PUD
smoking
more than __ cigarettes/day increases risk of perforated peptic ulcer threefold
15
__ in high concentrations damages the gastric mucosal barrier
etoh
epigastric pain w. PUD is worse after
eating
BUN:Cr ratio in PUD is often
>30:1
why is BUN:Cr ratio elevated in PUD
blood is absorbed as it passes through small bowel → decreased renal perfusion
what do higher BUN:Cr ratios indicate
higher likelihood of bleeding from UGI source
common EGD findings of PUD
oozing gastric hemorrhage
nonbleeding visible vessel
ddx for UGIB
PUD
esophagitis
angiodysplasia
portal HTN
mallory-weiss syndrome
UGI tumor
4 rf for PUD
h.pylori
nsaids
physiologic stress
excess gastric acid
etiology of NSAID induced PUD
prostaglandin/COX-1 inhibition → mucosal damage
abnormal dilated tortuous vessel in UGI
angiodysplasia
3 rf for angiodysplasia
renal dz
aortic stenosis
hereditary
peptic ulcers are defects in __ mucosa (2)
that extend thru the __
and persist dt __
gastric or duodenal
muscularis mucosa
acidic gastric acid
NSAIDs are associated w. __ ulcers
and increased risk of __
refractory
complications
all pt’s w. PUD should undergo __ testing
H.pylori
when can h.pylori testing be done
bx during EGD
t/f: if actively bleeding, a negative bx rules out H.pylori
F!
if h.pylori test is negative in active bleeding pt, what 2 tests can be used to confirm negative dx
urea breath
stool antigen
ASAP tx for PUD (4)
2 large bore IVs - at least 16 g
NPO
bolus of 500-1000 cc of fluids
GI consult for EGD
transfusion threshold
Hgb 7
transfusion threshold for high risk PUD pt
< 8
indication for high risk PUD pt
CAD
other tx considerations for PUD
IV esomeprazole OR pantoprazole
stop NSAIDs
dosing for esomeprazole or pantoprazole if pt is actively bleeding
80 mg
if pt needs to stay on ASA, what reduces risk of ulcer complications/recurrence
maintenance PPI therapy →
omeprazole 20 mg
continued tx for all PUD pt’s should include __ to facilitate healing
PPI → omeprazole 20-40 mg qd
indications for complicated PUD (4)
bleeding
perforation
penetration
gastric outlet obstruction
complicated PUD pt’s should get __ to facilitate healing
IV PPI
t/f: PPIs cause stronger acid suppression than H2 blockers and control sx faster and have higher healing rates
T!
__ pH levels stabilize clots and heal NSAID related ulcers more effectively than H2 blockers
higher
T/F: combining PPIs and H2 blockers is beneficial to PUD pt’s
F!
when can a pt w. an actively bleeding ulcer be switched from IV to PO PPI
72 hours after endoscopy
dose and duration for PO PPI for pt who has been switched from IV to PO
omeprazole 20 mg x 4-12 weeks
__ can heal duodenal ulcers but are not recommended for peptic ulcers (2)
antacids
sucralfate
2 lifestyle recommendations for PUD
stop smoking
limit etoh to 1 drink/day
2 tools to calculate PUD risk and outpt management
glasgow blatchford score (GBS)
rockfall score
when is GBS calculated
at patient presentation
doesn’t need EGD
when is rockfall calculated
after endoscopy
what factors does GBS use (8)
BUN
Hgb
SBP
pulse
presence of melena
syncope
hepatic dz
cardiac failure
what factors does rockfall use (5)
age
presence of shock
comorbidity
dx
endoscopy results
indications for d.c post endoscopy (3)
no comorbidities
stable vitals
normal Hgb
2 indications for somatostatin/octreotide
endoscopy not available
help stabilize pt before definitive therapy can be done
how do somatostatins/octreotide work
reduce splanchnic blood flow
inhibit gastric acid secretion
+/- protective effect on gastric cells
what 2 therapies are much more effective for PUD than somatostatin/octreotide
PPI
endoscopy
__ can predict recurrent peptic ulcer hemorrhage
EGD findings
classification that is used to objectify EGD findings for PUD
Forrest
in forrest classification, what counts as a stigmata of recent hemorrhage
anything other than a clean ulcer base
what are the forrest classifications (6)
spurting hemorrhage
oozing hemorrhage
nonbleeding visible vessel
adherent clot
flat pigmented spot
clean ulcer base
3 EGD tx for PUD
thermal coagulation therapy
hemostatic clips
+/- injection therapy
what is EGD injection therapy
epinephrine
who determines risk for rebleeding in PUD pt
GI
generally, when can you restart anticoagulation/antiplatelet therapy (ASA) after PUD tx
1 day following endoscopic hemostasis
t/f: data shows that restarting ASA for secondary prevention reduces mortality risk in pt’s w. CV or cerebrovascular dz w. bleeding from PUD
T!
