W10 GORD, Peptic Ulcer, H.pylori Flashcards
What is GORD?
- Gastro-oesophageal reflux disease
- Usually caused by weakening/relaxation in lower oesophageal sphincter
- Acid from stomach leaks up into oesophagus
Symptoms of GORD? (5)
Acid from stomach leaks up into oesophagus, causing symptoms
* Heartburn
* Acid reflux
* Bad breath
* Bloating / belching
* Nausea / vomiting
What are the Risk factors/Triggers of GORD?
- Smoking
- Alcohol
- Coffee
- Chocolate
- Fatty Foods
- Being Overweight
- Stress
- Medicines (calcium channel blockers, nitrates, NSAIDs etc)
- Tight clothing
- Pregnancy
How can GORD be diagnosed?
Diagnosis is usually made solely on symptoms
* Should take a full drug history to identify any possible drug causes
-Calcium antagonists, nitrates, theophyllines, bisphosphonates, corticosteroids and non-steroidal anti-inflammatory drugs
- Will unlikely perform any other tests to confirm GORD diagnosis
- May perform other tests to investigate other causes of symptoms
-Urea breath test for H. pylori infection
-Endoscopy for gastric cancers
GORD lifestyle advice?
- Lose weight if overweight
- Eating small, frequent meals rather than large meals
- Eat several hours before bedtime
- Cut down on tea/coffee/cola/alcohol
- Avoid triggers, e.g. rich/spicy/fatty foods
- If symptoms worse when lying down, raise head of bed (do not prop up
head with pillows) - Avoid tight waistbands and belts, or tight clothing
- Stop smoking
GORD OTC Management? (3)
- Antacid: Pepto-Bismol®, Rennie®
- Alignate: Gaviscon Advance®
- Dual Product: Gaviscon Dual Action®, Peptac®
- PPI or H2 receptor antagonists
- Longer acting, but take longer to work than antacids
- Do not take both at same time, one or the other
- Quite strict criteria of who you can supply PPI to (recent POM to P switch)
- Max 2-4 weeks treatment, then refer to G
GORD red flags needing referral:
- Patients over 55 years with new onset symptoms
- Patients over 55 years with unexplained dyspepsia that hasn’t responded to 2 weeks of treatment
- Patients who have continuously taken remedies for 4 weeks (risk of rebound indigestion)
- Pregnant or breastfeeding
- Not responded to OTC treatment
Red flag symptoms of GORD?
- Unintentional weight loss
- Epigastric mass
- Stomach pain, pain/difficulty when swallowing
- Persistent vomiting
- Jaundice
- Signs suggestive of GI bleed
GORD POM Management
Once confident patient has GORD and no other sinister condition, can offer
full dose PPI for 4-8 weeks
* PPI = Proton Pump Inhibitor
* If symptoms recure after this treatment, can offer PPI at lowest effective
dose to control symptoms
- If inadequate response to PPI, offer H2 receptor antagonist
PPI doses for GORD:
Esomeprazole
Lansoprazole
Omeprazole
Pantoprazole
finish*
PPIs- Issues to be aware of? (4)
Interactions?
Side effects?
Some issues to be aware of:
* Subacute Cutaneous Lupus Erythematosus
-Very low risk of SCLE caused by PPI
-Can be weeks, months or years after exposure
-If patient on PPI develops lesions in sun-exposed skin areas, consider this as diagnosis- consider stopping PPI & advise to avoid sunlight exposure
-Usually resolves upon PPI withdrawal
* Risk of fractures
-Long-term use (especially if high dose for over 1 year in elderly) can increase risk of bone fractures
* Risk of GI infections
-Especially C.diff. Neutralises stomach acid so body doesn’t kill bugs
-With-hold PPI if on broad spectrum antibiotics or confirmed C. diff
* Risk of masking gastric cancer
-May mask the symptoms, which is why careful questioning needed before giving
* Interactions
-Some (e.g. omeprazole) interact with clopidogrel – significant as reduces antiplatelet effect
-All reduce absorption of vitamin B12 if used long-term – risk of developing anaemia that needs treatment
* Side effects
-Common: abdo pain, nausea, vomiting, constipation, diarrhoea
* Rarer, but to be aware of: dec platelets, dec sodium, dec magnesium (should monitor this as affects heart)
H2 Receptor Antagonists
Examples: ranitidine, famotidine, cimetidine
-BD dosing
* Issues to be aware of:
* Risk of masking gastric cancer
-May mask the symptoms, which is why careful questioning needed before giving
* Side effects
-Common: Constipation, diarrhoea, fatigue, headache
* Interactions
-Most have few interactions
-Exception is cimetidine- potent CYP enzyme inhibitor, lots of major interactions
* Supply chain
-Massive ongoing manufacturing issues with ranitidine
-Some clinicians switching to famotidine, most prescribing PPI instead
What are peptic ulcers?
- Sores that develop in lining of stomach and intestines
- Gastric ulcer = in stomach
- Duodenal ulcer = in duodenum (small intestine)
What are the Signs and symptoms of peptic ulcers? (5)
- Burning or gnawing pain in centre of abdomen
- Indigestion
- Heartburn
- Nausea and vomiting
- Pain can last minutes to hours, and can come and go for several days, weeks or
months
What are the
Risk factors (2) & Causes (3)
of Peptic Ulcers?
- More common in people aged 60 or over, and in males
-Caused when protective lining of stomach is damaged
- Helicobacter pylori (H. pylori) infection
o Bacteria damages mucous coating of stomach and duodenum lining
o Once lining is damaged, hydrochloric acid of stomach can reach the lining
o The acid and the bacteria irritate the lining, causing an ulcer - Taking non-steroidal anti-inflammatories (NSAIDs)
o NSAIDs (e.g. aspirin, ibuprofen, naproxen) block COX-1 enzymes
o Enzyme plays role in GI mucosal protection – if blocked, protective lining becomes vulnerable to stomach acid, causing an ulcer - Sometimes caused by ‘stress’ (e.g. in intensive care) or some foods (patchy evidence)
What are the complications of peptic ulcers? (3)
- Bleeding at site of ulcer
-Slow bleed – anaemia
-Rapid and severe – vomit blood, melaena = risk of death - Stomach perforation
-GI bacteria can infect lining of abdomen – peritonitis
-GI bacteria may go into bloodstream - sepsis - Gastric obstruction
-Scarred or inflamed stomach can stop passage of food to gut
-Will repeatedly vomit, won’t take on nutrients
What are the steps in the Diagnosis of Peptic Ulcers? 4)
- Take a full history
* Especially to identify NSAID use
* Signs and symptoms - Physical abdo exam
* Feel for mass, listen for bowel sounds, tap abdomen to check for tenderness or pain - Urea breath test
* To identify H. pylori infection - Might also refer for endoscopy
* Small camera used to look directly inside stomach to visualise ulcer
* May be used to take biopsy – test for H. pylori and/or cancer
Peptic ulcer POM Management:
What POM is offered?
- If due to NSAIDs
-Stop NSAID treatment if possible
-Full dose PPI or H2RA therapy for 8 weeks to help ulcer heal - If due to H. pylori
-Offer H. pylori eradication course - If due to NSAIDs AND H. pylori
-Full dose PPI or H2RA therapy for 8 weeks to help ulcer heal first
-THEN offer H. pylori eradication course - If not due to NSAIDs or H. pylori
-Full dose PPI or H2RA for 4-8 weeks
Monitoring and follow-up of peptic ulcers:
- Ensure only takes PPI as a course
- Ideally want to avoid long-term treatment
- Managing pain without NSAID
- Offer alternative analgesia, e.g. paracetamol or low-dose ibuprofen
- If still want NSAID, try low dose short courses on PRN basis, and co-prescribe PPI (should be regularly reviewed)
- Could also consider COX-2 selective NSAID, co-prescribe PPI too
- If symptoms persist
-Exclude non-adherence, inadvertent NSAID use or drugs causing ulcers
-Exclude other cause, e.g. malignancy, Crohn’s, Zollinger-Ellison syndrome - If symptoms recur
-Trial low-dose PPI, on a PRN basis
-Might get rebound dyspepsia on stopping PPI, so PRN use of antacids during this time may help
What is H.pylori?
- Helicobacter pylori is a Gram negative bacteria found in the stomach
- First identified in 1980s as being involved in ulceration and gastritis
- One of the most common causes of peptic ulcer diseas
H. Pylori risk factors/triggers? (4)
- Transmission is through direct contact with saliva, vomit or stool of infected person, or via contaminated food or water
- Living in crowded conditions
- Living without a reliable source of clean water
- Living with someone who has H. pylori infection
- More common in developing countries
What are the complications of H.pylori infection? (3)
- Peptic ulcers
- Gastritis- Inflammation of stomach lining
- Stomach cancer
- Important to identify cases and treat properly
What is the diagnostic test for H.pylori?
Carbon-13 urea breath test
* Drink liquid containing urea
* If H. pylori present, will break down urea into carbon dioxide
* Patient breathes into bag, which is sent to lab for testing
* If breath sample has higher than normal levels of CO2 , test is positive for H. pylori infection
* False negatives may occur if test is within 2 weeks of PPI use or 4 weeks of antibiotic use
* Other options are stool test or blood test
-Neither routinely used due to not being able to reliably diagnose H. pylori infection
Management – 1st Line Triple Therapy for H.pylori infection
Non-penicillin allergy?
Penicillin allergy?
No penicillin allergy:
1. Amoxicillin
2. Clarithromycin
3. Any PPI e.g. Omeprazole
Penicillin Allergy:
1. Clarithromycin
2. Metronidazole
3. Any PPI
Both for 7 days
Management – 2nd Line Triple Therapy for H.pylori infection
Non-penicillin allergy?
Penicillin allergy?
- Amoxicillin 1g PO BD
Clarithromycin 500mg PO BD
OR - Metronidazole
400mg PO BD
(Use whichever wasn’t used 1st line) - Any PPI E.g. Omeprazole 20mg PO BD
7 days
Penicillin allergy:
1. Levofloxacin 250mg PO BD
2. Metronidazole 400mg PO BD
3. Any PPI E.g. Omeprazole 20mg PO BD
7 days
Management – 3rd Line Triple Therapy for H.pylori infection
Non-penicillin allergy?
Penicillin allergy?
(for info as not as common)
Used on specialist advice only
-10 days of treatment
* No penicillin allergy:
-PPI + Bismuth Subsalicylate + Any 2 Abx listed not previously used
-Other Abx options: Rifabutin or Furazolidone
* Penicillin allergy:
* PPI + Bismuth Subsalicylate + Rifabutin / Furazolidone
Points to Consider for H.Pylori: * H. pylori strain may be resistant
* Need for 2nd or 3rd line drugs, which usually have more side effects
* If 2nd line doesn’t work, may be worth referring for endoscopy to undergo culture
and susceptibility testing
* Diarrhoea
* If diarrhoea develops, should consider C. diff infection
* Need to confirm this and review ongoing treatment need
* Adherence
* Regimen can be complex and high tablet burden
* Ensure patient understands important of finishing course
The Antibiotics
Amoxicillin,Metronidazole, Clarithromycin, Tetracycline, Levofloxacin
Drug class?
Side effects?
Cautions?
- Amoxicillin
-Is a penicillin, so double-check allergy status
-Common s/e: Diarrhoea, nausea, vomiting - Metronidazole
-No common s/e of note
-Avoid alcohol whilst taking and for 48 hours after completion – risk of disulfiram-like reaction (flushing, nausea, severe vomiting etc) - Clarithromycin
-Type of macrolide antibiotic - Caution: can prolong QT interval (may lead to torsades de pointes and death), so avoid concurrent use with other QT prolonging drugs
-Common s/e: GI disturbances, headache - Lots of significant interactions, so always check full Hx
- Tetracycline
-Type of tetracycline antibiotic
-Common s/e: GI disturbances, headaches
-Contraindicated in children under 12 – binds to calcium, so deposition in growing bones and teeth leading to staining and dental hypoplasia
-Dairy produce can decrease exposure, so take 1 hr before or 2 hrs after dairy - Levofloxacin
-Type of quinolone antibiotic
-Risk of tendon damage which can be disabling – stop at first sign of tendon/muscle pain
-Caution: can prolong QT interval
-Long list of cautions – including in those with seizures as can cause convulsions
2 MoA of Gaviscon?
Antacid- neutralise acid (bicarbonate)
Forming a raft- suppress acid from coming out of the sphincter (reduce gastric acid production.
Why is omeprazole given as a gastro-resistant capsule?
Bypasses the stomach- not broken down
It is a weak base- if broken down in the stomach it will become protonated (ionised) so cannot be easily absorbed systemically
intestine is basic
Pro drug- needs to be converted into sulphonamide based on protonation + rearrangements
MoA of Omeprazole?
Proton Pump inhibitor
Inhibits ATPase Pump
Parietal cells release H+ and Cl-
The pump is inhibited- so H+ is not released into stomach which decreases the acidity.
Omeprazole counselling points? (4)
Do not open capsules
Take 1 hour before food
Do not crush or chew tablets or capsules
If swallowing difficulties- you can open and disperse pellets in water (enteric coating is inside of the capsule)
What is the difference between Panadol Advance and Panadol Actifast?
Differences in disintegrants:
Advance- Crospovidone
Activist- Sodium starch glycolate
Both are super disintegrates.
