PUD/GERD Flashcards
Actigall
For gallstones, cholestasis
Ursodeoxycholic Acid
Naturally occurring bile acid
Reduces cholesterol secretion from liver
Dissolves gallstones <1cm in bile
Components of bile
Cholesterol
Bile acids: solubilize
Phosphatidyl choline: solubilize
Bilirubin
Pancrealipase
Lipase, amylase, protease (trypsin)
Mechanism of acid secretion
G cells secrete gastrin, gastrin binds to CCK on enterochrommafin cells, ECL stimulate histamine release, histamine binds to H2R on parietal cell to secrete acid
Drugs that target receptors for acid secretion
H2 antagonists, proton pump inhibitors, prostaglandins, muscarinic antagonists
Proton pump inhibitors
Target H+K+ ATPase, covalently bind to -SH group
Take 30 min before meals
Need enteric coating to bypass acid
Goal: pH>4
Omeprazole, Nexium S, lansoprazole
Caution: hypomag, hypoka, QT risk
Can combo with H2RA
H2 antagonists
Target H2 on parietal cells
Cimetidine DDI profile CYP 1A2, 2C9, 2D6 inhibition
May cause headache, drowsiness, confusion
Thrombocytopenia <100,000
Antacids
Acid neutralization
Last longer with food
AC - aluminum constipation
MD - magnesium diarrhea
Sodium may exacerbate CHF
Caution Na, Mg, Al in CrCl<30
Misoprostol
Prostaglandins inhibit acid secretion and increase secretion of protective mucus
Prostaglandin analog, bind to EP3 receptor on parietal cells decrease gastric acid secretion, increase HCO3 buffer
NSAIDs inhibit PG and induce mucosal injury
Tolerable dose as effective as PPI
Contraindicated in pregnancy
Sucralfate
Inhibit hydrolysis of mucosal proteins by Pepsin, protective barrier
Stimulate local production of prostaglandins
Take on empty stomach, separate from phenytoin, digoxin, warfarin
Pirenzipine
M1 receptor antagonist on ENS cell
H. Pylori
Gram negative, microaerobe, potent urease, prevalent in blacks
Destroy mucosa, inflammation, ulceration, 70% chronic gastritis
Decrease somatostatin,increase gastrin
Amox- beta lactam gram(-)
Clarithro- macrolide interferes protein synthesis
Metronidazole- target anaerobes
GERD
Heartburn, regurgitation, excess saliva
Empiric response to PPI 20mg BID
Caution anticholinergics that reduce gastric motility, pregnancy
Lifestyle,elevate head of bed, smoking cessation, avoid alcohol, caffeine, spicy foods, avoid tight clothing, avoid eating late
Asthma is common
Meds that lower LES tone
Anticholinergic clozapine
Caffeine
Alcohol
GI drug irritants
Alendronate
Aspirin
NSAIDs
Iron
GERD Guidelines
1) lifestyle modifications
2) empiric therapy: PPI
H2RA if moderate
3) endoscopy if >55 GERD, overweight, or alarm symptoms (bleeding, dysphagia, vomiting)
4) promotility: metoclopramide, bethanechol
Baclofen: reduce LES relaxation
Dyspepsia
Upset stomach, feeling full
>55 endoscopy
<55 PPI, rifaximin, probiotics, test for H. pylori
Tests for H. Pylori
Stool antigen 95% sensitive
UBT 90-96% sensitive, good to confirm eradication
Biopsy urease test sensitive
BUS sensitive
Biopsy urease test 95-100% specific
Culture 100% specific
BC specific
SPIN: specific pos rule in
SNOUT: sensitive neg rule out
H Pylori antibiotics
10 days course of therapy
OAC - Omeprazole, Amox, clarithro
LAC - lanso, Amox, clarithro BID
Amox preferred, to reserve metronidazole
Salvage BMT, bismuth, metro, tetracyc
BMT QID (less adherence), PPI BID
Bismuth can cause black ashy stool
PUD doses
For ulcer healing
Famotidine 20mg BID
Ranitidine 150 mg BID
Omeprazole 20mg daily
Lansoprazole 30mg daily
Pantoprazole 40mg daily
Sucralfate on empty stomach
NSAIDs Ulcer risk
Inhibit prostaglandins, COX1
High risk: perixicam, ketorolac
Medium risk: naproxen
Low risk, nabumetone, ibuprofen
Male >60 high dose ibuprofen to
Female > 65
Smoking, alcohol in cirrhotics
Corticosteroids
Recommend PPI, cox2selective, misoprostol
Stress related mucosal disease
Common in ICU patients (critically ill
Head trauma, burns)
Due to chronic ischemia
Eating food, enteral nutrition is important
Nasogastric tube PPI, oral PPI preferred over
Parenteral PPIS, H2RA prophylaxis
Prophylaxis if >50mg prednisone, serious injury
Barrett’s esophagus
Squamous to columnar epithelium
Precancerous condition
Esophageal cancer increases with frequency, duration, and severity of reflux symptoms
Need long term PPI
Esophagitis
Mild
Moderate erosions
Severe stricture
Ambulatory pH testing
May be helpful in endoscopy negative, atypical GERD, non-cardiac chest pain
Peptic ulcer disease
Protective: bicarbonate, prostaglandins, mucus production
Always tested for and treated for His. Pylori if infected
Break in mucosa >5mm
H. Pylori, pepsin
ASA/NSAID
Smoking
Duodenal 90% H. Pylori
Gastric 70% HPylori, 30 NSAIDs
Zollinger-Ellison syndrome
Gastrin secreting tumor
Gallstone risk factors
Fat
Fertile
Female
Over forty
Cholecystectomy if recurrent
Acute Ulcer GI bleed
Blood transfusion
