PUD E2 Flashcards
What is the definition of an ulcer given by Dr. W?
Perforation into the submucosa > 5mm.
What are the symptoms of PUD?
- Dypepsia (gnawing, epigastric pain)
- Early Satiety
- Pain which wakes the patient up from sleep.
What is the #1 complication of PUD?
GI Bleeds
What are the two main causes of PUD?
1 = Helicobacter pylori
2 = NSAIDs
How do NSAIDs cause PUD?
- Inhibit COX ā> Decreased Prostaglandins which help to maintain gut integrity.
- Direct Mucosal Injury
- Decrease Gastric Mucosal BF
- Increase Acid Secretion (Increase HCl, decrease HCO3-)
- Decrease epithelial proliferation, phospholipid secretion, and mucus secretion.
How is PUD of H.pylori etiology diagnosed?
- Invasive Dx = EGD or Endoscopy w/ sample and culture.
- Non-Invasive = Antibody Blood Test or Urea Breath Test
How does the urea breath test work to diagnose H. pylori PUD?
H. pylori converts urea gastric juice to ammnoia and HCO3-. The bicarbonate can be picked up in the breath.
How is the eradication of H. pylori confirmed?
Fecal Antigen Test
How are H. pylori PUDs treated?(What is Triple/Quad Therapy?)
Antibiotics + PPI for 14 days.
- Triple Therapy: PPI BID + Clarithromycin 500 mg BID + Amoxicillin 1 g BID
- Bismuth Quad Therapy: PPI BID, Bismuth Product, Tetracycline 500 mg QID , Metronidazole 250 mg QID.
Bismuth Quad is preferred.
What is triple therapy for H. pylori? Why is not used frequently anymore?
PPI BID + Clarithromycin 500 mg BID + Amoxicillin 1 gram BID.
Not used much anymore due to macrolide resistance concerns.
What is bismuth Quad therapy?
PPI BID, Bismuth product, Tetracycline 500 mg QID, Metronidazole 250 mg QID.
What is the preferred treatment for H. pylori?
Bismuth Quad Therapy
What it the # 1 drug toxicity in the U.S.?
NSAID Induced PUD
(25% of users develop PUD, 2-4% develop upper GI bleeds.)
NSAID PUD RFs
Age >65
Hx of PUD
Concomitant use of steroids
Non-selective NSAIDs
Concomitant Anticoagulants (heparin, DOACs)
Concomitant ANtiplatelets
High NSAID doses s
True or False: All patients on DAPT w/ aspirin and a P2Y12 inhibitor automatically require QD PPI to prophylactically prevent PUD due to increase bleed risk.
True
Who should be prophylactically treated with a PPI to prevent PUD associated with NSAIDs?
1.. patients meeting multiple risk factors.
2. Patients on DAPT
How is NSAID induced PUD treated?
- PPI Daily for 4-8 weeks if NSAID can be discontinued.
- If the NSAID can not be d/cād may need to consider using a chronic PPI. (In the case of aspirin 81 mg QD)
What are alternative pain options for patients who have experienced NSAID induced PPI?
- Tylenol 500 mg
- COX-2 Agents (Celebrex)
What prostaglandin analog can be used w/ NSAIDs to help reduce the risk of PUD? What is a risk of using this medication?
- Misoprostil
- Misoprostil is teratogenic.
What are the symptoms of an Upper GI Bleed?
Hematemesis
Melana
Light Headedness
Chest Pain
Hypotension
Tachycardia
Decreased HgB
Decrease HcT
How are Upper GI Bleeds managed?
Fluid Management: IV Isotonic Bolus Fluids (NS/ lactated Ringers)
Packed Red Blood Cells: Only if HgB is <7 = 1 unit = 1 g/dL increase
Oxygen if less than 92%
Reverse Anticoagulation if applicable.
Endoscopic Management (Local Targeted therapy with epinephrine.)
Acid Suppression.
How is acid suppression performed for patients with upper GI bleeds?
- IV High Dose PPI for 3 days (Pantoprazole or Esomeprazole)
Day 1 = 80 mg Bolus
Day 2/3 = 40 mg IV BID
Then
BID PO therapy x 2 weeks
Then
QD PO therapy x 1 week.
