PUD E2

Question 1

What is the definition of an ulcer given by Dr. W?

Answer 1

Perforation into the submucosa > 5mm.

Question 2

What are the symptoms of PUD?

Answer 2

1. Dypepsia (gnawing, epigastric pain)
2. Early Satiety
3. Pain which wakes the patient up from sleep.

Question 3

What is the #1 complication of PUD?

Answer 3

GI Bleeds

Question 4

What are the two main causes of PUD?

Answer 4

1 = Helicobacter pylori

2 = NSAIDs

Question 5

How do NSAIDs cause PUD?

Answer 5

1. Inhibit COX –> Decreased Prostaglandins which help to maintain gut integrity.
2. Direct Mucosal Injury
3. Decrease Gastric Mucosal BF
4. Increase Acid Secretion (Increase HCl, decrease HCO3-)
5. Decrease epithelial proliferation, phospholipid secretion, and mucus secretion.

Question 6

How is PUD of H.pylori etiology diagnosed?

Answer 6

1. Invasive Dx = EGD or Endoscopy w/ sample and culture.
2. Non-Invasive = Antibody Blood Test or Urea Breath Test

Question 7

How does the urea breath test work to diagnose H. pylori PUD?

Answer 7

H. pylori converts urea gastric juice to ammnoia and HCO3-. The bicarbonate can be picked up in the breath.

Question 8

How is the eradication of H. pylori confirmed?

Answer 8

Fecal Antigen Test

Question 9

How are H. pylori PUDs treated?(What is Triple/Quad Therapy?)

Answer 9

Antibiotics + PPI for 14 days.

1. Triple Therapy: PPI BID + Clarithromycin 500 mg BID + Amoxicillin 1 g BID
2. Bismuth Quad Therapy: PPI BID, Bismuth Product, Tetracycline 500 mg QID , Metronidazole 250 mg QID.

Bismuth Quad is preferred.

Question 10

What is triple therapy for H. pylori? Why is not used frequently anymore?

Answer 10

PPI BID + Clarithromycin 500 mg BID + Amoxicillin 1 gram BID.

Not used much anymore due to macrolide resistance concerns.

Question 11

What is bismuth Quad therapy?

Answer 11

PPI BID, Bismuth product, Tetracycline 500 mg QID, Metronidazole 250 mg QID.

Question 12

What is the preferred treatment for H. pylori?

Answer 12

Bismuth Quad Therapy

Question 13

What it the # 1 drug toxicity in the U.S.?

Answer 13

NSAID Induced PUD
(25% of users develop PUD, 2-4% develop upper GI bleeds.)

Question 14

NSAID PUD RFs

Answer 14

Age >65
Hx of PUD
Concomitant use of steroids
Non-selective NSAIDs
Concomitant Anticoagulants (heparin, DOACs)
Concomitant ANtiplatelets
High NSAID doses s

Question 15

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.

Answer 15

True

Question 16

Who should be prophylactically treated with a PPI to prevent PUD associated with NSAIDs?

Answer 16

1.. patients meeting multiple risk factors.
2. Patients on DAPT

Question 17

How is NSAID induced PUD treated?

Answer 17

1. PPI Daily for 4-8 weeks if NSAID can be discontinued.
2. If the NSAID can not be d/c’d may need to consider using a chronic PPI. (In the case of aspirin 81 mg QD)

Question 18

What are alternative pain options for patients who have experienced NSAID induced PPI?

Answer 18

1. Tylenol 500 mg
2. COX-2 Agents (Celebrex)

Question 19

What prostaglandin analog can be used w/ NSAIDs to help reduce the risk of PUD? What is a risk of using this medication?

Answer 19

1. Misoprostil
2. Misoprostil is teratogenic.

Question 20

What are the symptoms of an Upper GI Bleed?

Answer 20

Hematemesis
Melana
Light Headedness
Chest Pain
Hypotension
Tachycardia
Decreased HgB
Decrease HcT

Question 21

How are Upper GI Bleeds managed?

Answer 21

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.

Question 22

How is acid suppression performed for patients with upper GI bleeds?

Answer 22

1. 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.