PUD/GERD

Question 0

Actigall

For gallstones, cholestasis

Answer 0

Ursodeoxycholic Acid
Naturally occurring bile acid

Reduces cholesterol secretion from liver

Dissolves gallstones <1cm in bile

Question 1

Components of bile

Answer 1

Cholesterol
Bile acids: solubilize
Phosphatidyl choline: solubilize
Bilirubin

Question 2

Pancrealipase

Answer 2

Lipase, amylase, protease (trypsin)

Question 3

Mechanism of acid secretion

Answer 3

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

Question 4

Drugs that target receptors for acid secretion

Answer 4

H2 antagonists, proton pump inhibitors, prostaglandins, muscarinic antagonists

Question 5

Proton pump inhibitors

Answer 5

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

Question 6

H2 antagonists

Answer 6

Target H2 on parietal cells

Cimetidine DDI profile CYP 1A2, 2C9, 2D6 inhibition

May cause headache, drowsiness, confusion
Thrombocytopenia <100,000

Question 7

Antacids

Answer 7

Acid neutralization

Last longer with food

AC - aluminum constipation
MD - magnesium diarrhea
Sodium may exacerbate CHF

Caution Na, Mg, Al in CrCl<30

Question 8

Misoprostol

Prostaglandins inhibit acid secretion and increase secretion of protective mucus

Answer 8

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

Question 9

Sucralfate

Answer 9

Inhibit hydrolysis of mucosal proteins by Pepsin, protective barrier

Stimulate local production of prostaglandins

Take on empty stomach, separate from phenytoin, digoxin, warfarin

Question 10

Pirenzipine

Answer 10

M1 receptor antagonist on ENS cell

Question 11

H. Pylori

Answer 11

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

Question 12

GERD

Answer 12

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

Question 13

Meds that lower LES tone

Answer 13

Anticholinergic clozapine
Caffeine
Alcohol

Question 14

GI drug irritants

Answer 14

Alendronate
Aspirin
NSAIDs
Iron

Question 15

GERD Guidelines

Answer 15

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

Question 16

Dyspepsia

Answer 16

Upset stomach, feeling full
>55 endoscopy
<55 PPI, rifaximin, probiotics, test for H. pylori

Question 17

Tests for H. Pylori

Answer 17

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

Question 18

H Pylori antibiotics

Answer 18

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

Question 19

PUD doses

For ulcer healing

Answer 19

Famotidine 20mg BID
Ranitidine 150 mg BID

Omeprazole 20mg daily
Lansoprazole 30mg daily
Pantoprazole 40mg daily

Sucralfate on empty stomach

Question 20

NSAIDs Ulcer risk

Inhibit prostaglandins, COX1

Answer 20

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

Question 21

Stress related mucosal disease

Common in ICU patients (critically ill
Head trauma, burns)
Due to chronic ischemia

Answer 21

Eating food, enteral nutrition is important

Nasogastric tube PPI, oral PPI preferred over
Parenteral PPIS, H2RA prophylaxis

Prophylaxis if >50mg prednisone, serious injury

Question 22

Barrett’s esophagus

Answer 22

Squamous to columnar epithelium

Precancerous condition

Esophageal cancer increases with frequency, duration, and severity of reflux symptoms

Need long term PPI

Question 23

Esophagitis

Answer 23

Mild
Moderate erosions
Severe stricture

Question 24

Ambulatory pH testing

Answer 24

May be helpful in endoscopy negative, atypical GERD, non-cardiac chest pain

Question 25

Peptic ulcer disease

Protective: bicarbonate, prostaglandins, mucus production

Always tested for and treated for His. Pylori if infected

Answer 25

Break in mucosa >5mm

H. Pylori, pepsin
ASA/NSAID
Smoking

Duodenal 90% H. Pylori
Gastric 70% HPylori, 30 NSAIDs

Question 26

Zollinger-Ellison syndrome

Answer 26

Gastrin secreting tumor

Question 27

Gallstone risk factors

Answer 27

Fat
Fertile
Female
Over forty

Cholecystectomy if recurrent

Question 28

Acute Ulcer GI bleed

Answer 28

Blood transfusion