W10 GORD, Peptic Ulcer, H.pylori

Question 1

What is GORD?

Answer 1

• Gastro-oesophageal reflux disease
• Usually caused by weakening/relaxation in lower oesophageal sphincter
• Acid from stomach leaks up into oesophagus

Question 2

Symptoms of GORD? (5)

Answer 2

Acid from stomach leaks up into oesophagus, causing symptoms
* Heartburn
* Acid reflux
* Bad breath
* Bloating / belching
* Nausea / vomiting

Question 3

What are the Risk factors/Triggers of GORD?

Answer 3

• Smoking
• Alcohol
• Coffee
• Chocolate
• Fatty Foods
• Being Overweight
• Stress
• Medicines (calcium channel blockers, nitrates, NSAIDs etc)
• Tight clothing
• Pregnancy

Question 4

How can GORD be diagnosed?

Answer 4

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

Question 5

GORD lifestyle advice?

Answer 5

• 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

Question 6

GORD OTC Management? (3)

Answer 6

• 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

Question 7

GORD red flags needing referral:

Answer 7

• 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

Question 8

Red flag symptoms of GORD?

Answer 8

• Unintentional weight loss
• Epigastric mass
• Stomach pain, pain/difficulty when swallowing
• Persistent vomiting
• Jaundice
• Signs suggestive of GI bleed

Question 9

GORD POM Management

Answer 9

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

Question 10

PPI doses for GORD:

Answer 10

Esomeprazole
Lansoprazole
Omeprazole
Pantoprazole
finish*

Question 11

PPIs- Issues to be aware of? (4)
Interactions?
Side effects?

Answer 11

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)

Question 12

H2 Receptor Antagonists

Answer 12

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

Question 13

What are peptic ulcers?

Answer 13

• Sores that develop in lining of stomach and intestines
• Gastric ulcer = in stomach
• Duodenal ulcer = in duodenum (small intestine)

Question 14

What are the Signs and symptoms of peptic ulcers? (5)

Answer 14

• 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

Question 15

What are the
Risk factors (2) & Causes (3)
of Peptic Ulcers?

Answer 15

• More common in people aged 60 or over, and in males
  -Caused when protective lining of stomach is damaged

1. 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
2. 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
3. Sometimes caused by ‘stress’ (e.g. in intensive care) or some foods (patchy evidence)

Question 16

What are the complications of peptic ulcers? (3)

Answer 16

• 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

Question 17

What are the steps in the Diagnosis of Peptic Ulcers? 4)

Answer 17

1. Take a full history
   * Especially to identify NSAID use
   * Signs and symptoms
2. Physical abdo exam
   * Feel for mass, listen for bowel sounds, tap abdomen to check for tenderness or pain
3. Urea breath test
   * To identify H. pylori infection
4. 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

Question 18

Peptic ulcer POM Management:
What POM is offered?

Answer 18

• 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

Question 19

Monitoring and follow-up of peptic ulcers:

Answer 19

• 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

Question 20

What is H.pylori?

Answer 20

• 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

Question 21

H. Pylori risk factors/triggers? (4)

Answer 21

• 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

Question 22

What are the complications of H.pylori infection? (3)

Answer 22

• Peptic ulcers
• Gastritis- Inflammation of stomach lining
• Stomach cancer
• Important to identify cases and treat properly

Question 23

What is the diagnostic test for H.pylori?

Answer 23

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

Question 24

Management – 1st Line Triple Therapy for H.pylori infection

Non-penicillin allergy?
Penicillin allergy?

Answer 24

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

Question 25

Management – 2nd Line Triple Therapy for H.pylori infection

Non-penicillin allergy?
Penicillin allergy?

Answer 25

1. Amoxicillin 1g PO BD
   Clarithromycin 500mg PO BD
   OR
2. Metronidazole
   400mg PO BD
   (Use whichever wasn’t used 1st line)
3. 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

Question 26

Management – 3rd Line Triple Therapy for H.pylori infection

Non-penicillin allergy?
Penicillin allergy?
(for info as not as common)

Answer 26

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

Question 27

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

Question 28

The Antibiotics
Amoxicillin,Metronidazole, Clarithromycin, Tetracycline, Levofloxacin

Drug class?
Side effects?
Cautions?

Answer 28

• 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

Question 29

2 MoA of Gaviscon?

Answer 29

Antacid- neutralise acid (bicarbonate)
Forming a raft- suppress acid from coming out of the sphincter (reduce gastric acid production.

Question 30

Why is omeprazole given as a gastro-resistant capsule?

Answer 30

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

Question 31

MoA of Omeprazole?

Answer 31

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.

Question 32

Omeprazole counselling points? (4)

Answer 32

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)

Question 33

What is the difference between Panadol Advance and Panadol Actifast?

Answer 33

Differences in disintegrants:
Advance- Crospovidone
Activist- Sodium starch glycolate
Both are super disintegrates.