week 4- Upper GI conditions - management+therapeutic options and referral

Question 1

what are the aims for treatment of Stomach and Duodenal Ulcer? what treatment

Answer 1

-identify and eradicate H.pylori 7 day triple therapy which normally is PPI, 2 ANTIBIOTICS AMOXIC, CLARI
-stop inappropriate therapy
• Reduce acid production to reduce gastritis and
enable mucosa to repair
• Block H2 or Proton Pump

Question 2

What is the management of GORD?

Answer 2

• Remove causative agent
• Anything which lowers the LOS
pressure
• Non-pharmacological advice
-Use rafting product
• E.g. gaviscon
• Reduce acid production to enable
recovery of oesophageal mucosa

Question 3

What are some non-pharmacological management for GORD?

Answer 3

 Diet
 Eat small meals
 Avoid food which lowers the LOS
pressure
 Avoid fatty foods - slow gastric
motility
 Avoid eating within 4 hrs & drinking
within 2 hrs of going to bed
 Avoid drugs which lower the LOS
pressure
 Avoid tight fitting clothes
 Lose weight
-Attention to posture 
 Avoid bending from the waist 
 Do not lie down after eating - increased
exposure of food to oesophageal lining
 Nocturnal heartburn symptoms raise the
head of the bed (15
-23cm)
- Stop smoking 
-Reduce alcohol intake

Question 4

how do you manage dyspepsia symptoms?

Answer 4

- Symptomatic
• Neutralise acid
• Reduce flatulence
• Prevent dislocation of acid
-All treatments available over the counter

Question 5

what are antacids?

Answer 5

are like Aluminium, Magnesium, Sodium & Calcium Salts and combine with HCL in stomach to neutrilise acid

Question 6

what will antacids do?

Answer 6

• Increase LOS pressure - by gastric alkalinisation
• Mucosal protection - stimulate prostaglandin synthesis
-tablets and liquids and cat faster
-Rapid relief of symptoms of heartburn & indigestion
• Avoid long term, frequent, continuous use:
• Only relieves symptoms in the short term, rather than prevention

Question 7

what are some side effects of using antacids?

Answer 7

• Side effects include constipation with aluminium & diarrhoea with magnesium
• Aluminium binds phosphate in gut
leading to osteoporosis
• Aluminium may be absorbed leading to neurotoxicity
• Rebound gastric acid secretion with prolonged use Sodium avoided in patients with hypertension and
cardiac problems
• Important drug interactions to consider
-Generally safe in pregnancy
• Sodium content?

Question 8

what are alginates? (gaviscon)

Answer 8

• Alginates (formulated with antacid)
• Form a high pH viscid mass (Raft), trapping air
bubbles and CO2
from the reaction of antacid with the
stomach contents
• Floats to top of stomach and protects oesophageal
mucosa from stomach contents

Question 9

what are dimethicome?

Answer 9

• Anti-foaming agent
• Reduces surface tension of intragastric air bubble
• Allows bubbles to escape - reducing bloating feeling

Question 10

what are H2 RECEPTORS antagonists and how do they work?

Answer 10

 Cimetidine, famotidine, nizatidine, ranitidine
 Compete for H2
receptor on parietal cells,
overridden by powerful stimulus such as a large
meal
-PUD
 high healing rates, no reduction in relapse(H.pylori would still be present)
GORD
 After 12 weeks, 80-90% of patients with mild
oesophagitis improved
 Not effective in moderate to severe GORD

Question 11

what are some side effects of H2 antagonists?

Answer 11

• 1-7% of patients suffer ADRs
• Only headache and dizziness > placebo
• Cimetidine - Gynaecomastia (development of breast tissue) 0.2%, impaired libido
• Nizatidine - Sweating, abnormal dreams
• Confusional states in elderly

Question 12

what are the interactions involved in H2 antagonists?

Answer 12

Interactions
• Cimetidine binds to P450
• phenytoin, theophylline, warfarin

Question 13

what are some H2 antagonists OTC?

Answer 13

• Ranitidine (Zantac 75)
• Symptomatic relief of heartburn, dyspepsia & hyperacidity
• 6 days continuous treatment maximum
• Sub-therapeutic dosages?
• Patients use them prophylactically

Question 14

WHAT ARE SOME PPI that help with reflux and gord?

Answer 14

Omeprazole, lansoprazole, pantoprazole,
esomeprazole
• Enteric coated preparations, absorbed in small intestine
• Blocks hydrogen-potassium ATPase enzyme
• Prolonged suppression of acid secretion
• 20mg omeprazole causes 80% of acid secretion for
24 hours, 40mg 100%
• Heal ulcers more rapidly than H2 antagonists. Healing
rate same at 8 weeks
• PPIs superior in the treatment of reflux/GORD

Question 15

what are some side effects of PPI?

Answer 15

 Short term side effects include nausea, diarrhoea,
flatulence, epigastric pain, dry mouth & headache
 Arthralgia & myalgia
- Concerns about bacterial overgrowth
 May increase risk of salmonella or helicobacter DUE TO ACID PROPERTY TO KILL BACTERIA
 Lansoprazole before food - food  bioavailability
 Rebound acid

Question 16

what is used for PPI OTC?patients, directions

Answer 16

• Omperazole 10mg and 20mg
• Indicated for reflux symptoms in > 18 year olds
• Swallowed whole with plenty of liquid
• 20mg daily until symptoms improved then 10mg
-Refer to GP
• If after 2 weeks still no relief
• If treatment required continuously for 4 weeks then
refer
• Patient is over 45 and present with new or changed
symptom

Question 17

what are some other drugs that can be used?

Answer 17

• Metoclopramide & Domperidone
  • Increases gastric emptying + LOS tone
  -Sucralfate
  • Polymerizes below pH4 to form a sticky gel
  • Protective barrier over ulcer (adheres strongly)
  • Physical protection and allows bicarbonate to restablish pH
  gradient
• Bismuth
  • May act similarly to sucralfate
  • Strong affinity for mucosa, especially in ulcer craters
  • May blacken teeth and stools
  -Misoprostol
  • Promotes ulcer healing by stimulating protective
  mechanisms – sometimes used with NSAIDs

Question 18

how do you know when to use which treatment? when to use H2 antagonists or Proton pump inhibitors?

Answer 18

• Functional dyspepsia, Gastritis or PUD
  • Removal of causative agents
  • Dietary changes
  • Symptomatic management

Question 19

how do you know when to use which treatment?when to use Alginate products or Proton pump inhibitors and NOT H2 antagonists?

Answer 19

• GORD

• Lifestyle & dietary changes

Question 20

when do you refer a patient?

Answer 20

• Patient over 45 with a new/changed
symptoms of heartburn or dyspepsia
• Continuous dyspepsia
• Increasing severity
• Weight loss, loss of appetite, sign of
anaemia
• Pain on exercise - cardiac origin?
• Dysphagia
• Unexplainable pain on swallowing
• Blood in vomit or stools