Peptic Ulcer Disease

duration of drug treatment for PUD?

4 to 8 weeks 8 weeks if gastric ulcer

about the diagnostic process: if patient is <55 years old and has no alarm features then the prevalence of H. pylori in the area determines the next step. If H. pylori prevalence is <10% what is the next step? >10%

<10%: PPI trial, if that fails, test and treat for H. pylori, if that fails consider EGD >10%: test and treat for H. pylori, if that fails then PPI trial, if that fails then consider EGD in Arizona we test and treat for H. pylori because prevalence is 20%

Which of the following H. pylori tests are non-invasive? RUT FAT UBT culture Histology antibody

FAT (fecal antigen test) UBT (urea breath test) antibody testing

the most common causes of peptic ulcer disease are what two things?

H. pylori and NSAID use

What drugs can be used to treat PUD?

H2RAs: ranitidine 150 mg BID or 300 nightly famotidine 20 mg BID or 40 mg nightly PPI: omeprazole 20 mg daily, lansoprazole 15 mg daily, rabeprazole 20 mg daily, pantoprazole 40 mg daily sucralfate: 1 gram 4 times daily

If patient has high GI risk of NSAID ulcer, but patient is uses NSAIDs, what should be done?

If low CV risk: find alternative therapy if possible, such as COX-2 inhibitor plus PPI or misoprostol if high CV risk: avoid NSAID or COX-2 inhibitors.

First line therapy for secondary prevention of NSAID ulcers is?

PPI

If a patient has moderate or high GI risk and low or high CV risk of NSAID ulcer, what agents are added if the patient is taking NSAID?

PPI or misoprostol

bismuth-containing quadruple therapy includes PPI, tetracycline, metronidazole, and bismuth What ADRs can a patient expect?

PPI: HA, diarrhea tetracycline: photosensitivity, GI upset metronidazole: metallic tatste, disulfiram-like reaction with alcohol, dyspepsia bismuth: darkening of tongue and stools, nausea, GI upset

Standard triple therapy regimen of H. pylori includes PPI, clarithromycin, and amoxicillin or metronidazole. Education about expectations and completing therapy is important because lack of adherence is a big issue with these regimens. What ADRs can the patient expect?

PPI: HA, diarrhea Amoxicillin: GI upset, HA, diarrhea metronidazole: metallic taste, disulfiram-like reaction with alcohol, dyspepsia Clarithromycin: diarrhea, GI upset, altered taste

concerning H. pylori treatment: what are the components of standard triple therapy? duration of therapy?

PPI: standard dose bid clarithromycin 500 mg bid amoxicillin or metronidazole 1000 or 500 mg bid 10-14 days

Which of the following tests of H. pylori is invasive (endoscopic)? RUT FAT UBT culture Histology antibody

RUT (rapid urease test): detect active H. pylori infection by testing for urease activity Histology: need 3 samples from different sites because H. pylori presence is not consistent. There is a high degree of sampling error and high cost of properly trained personnel culture: time consuming and costly

Which of the following H. pylori tests is the preferred method? RUT FAT UBT culture Histology antibody

Rapid urease test: it is low cost, rapid, and simple Histology: need 3 samples from different sites because H. pylori presence is not consistent. There is a high degree of sampling error and high cost of properly trained personnel culture: time consuming and costly antibody testing: often misused. Identifies bodies immunoloic reaction to H. pylori. Cannot distinguish between active infection or hx of infection. Cannot be used to tell if tx is working. fecal antigen test: effective, but dependent on patient accurately collecting stool sample

Which of the following H. pylori tests is the gold standard for post treatment testing? RUT FAT UBT culture Histology antibody

Urea breath test is gold standard for post treatment testing fecal antigen test also works but there may be some error on the patients part in collecting stool sample

T or F: H. pylori is a carcinogen.

Yayuh boi So it's kind of a big deal. Must treat it.

about the diagnostic process: if patient is >55 years of age or has alarm features, then an EGD should performed. What are alarm features?

alarm features are things that would clue us into things that are more harmful unintentional weight loss -> concern for cancer odynophagia or dysphagia -> concern for cancer jaundice -> bile obstruction symptoms of bleed

NSAIDs can cause ulcers and have higher annual death rates in the US than motor vehicle accidents. What are the GI risk factors? medications: anti_________, cort__________, anti________ _______ underlying medical illness history of _____ or complications age > __ years

anticoagulants, corticosteroids, antiplatelets serious underlying medical illness hx of ulcer or complications age > 65 years

about primary prevention of NSAID ulcers: cotherapy with ___, high dose _____, or _______stol replace NSAID with ___-2 inhibitor eradication of _______

cotherapy with PPI, high dose H2RAs, or misoprostol replace NSAID with COX-2 inhibitor eradication of H. pylori Note: she mentioned something in lecture while talking about COX-2 inhibitors like if pt is taking low dose aspirin, gastric protection goes away. So I'm thinking she's saying that there's no benefit of COX-2 inhibitor in this case.

general symptoms of PUD include: epigastric __________ heartburn abdominal _______ or ________ even when patient hasn't eaten

epgastric discomfort/pain heartburn abdominal fullness or cramping

PUD symptoms may vary based on ulcer location. If ingestion of food precipitates pain does this suggest gastric or duodenal ulcer? What if pain is often relieved by food?

gastric: ingestion of food often precipitates pain duodenal: pain often relived by food

Probiotics are benficial in improving adherence to therapy, however it is unclear its role in improving eradication rates. Promising candidates include: _____bacillus Lacto_____

lactobacillus lactoferrin

Which of the following H. pylori tests have decreased sensitivity with medications that reduce urease activity? RUT FAT UBT culture Histology antibody

rapid urease test urea breath test fecal antigen test For these want to d/c PPI for 2 weeks and d/c bismuth for 4 weeks prior to test.

what are the CV risk factors of NSAID ulcer? requirement of low dose ______ individuals with prior __ event ____etes hyper______ hyper________ ___sity

requirement of lose dose aspirin prior CV event diabetes hypertension hyperlipidemia obesity

Nonpharmacologic treatment includes: ________ cessation avoid ____ use avoid foods that exacerbate symptoms eliminating or reducing physiologic _____

smoking cessation avoid NSAID use avoid foods that exacerbate symptoms eliminating or reducing physiologic stress

Which treatment regimen for H. pylori is considered the gold standard? standard triple therapy bismuth-containing quadruple therapy sequential therapy concomitant therapy hybrid therapy

standard triple therapy is the gold standard (PPI, clarithromycin, and amoxicillin or metronidazole) bismuth-containing quadruple therapy (PPI, tetracycline, metronidazole, bismuth) is also a good choice but tetracycline is hard to get and increased drug burden. Sequential has not as good eradication rates Concomitant has had several cases of not eradicating H. pylori hybrid therapy is a complex regimen and therefore has increased risk of poor adherence

about complications of PUD: melena or hematemesis are signs of _____ __ bleed sharp, sudden pain is a sign of _________ and/or ___________ bloating, anorexia, nausea, weight loss, and vomiting are signs of ________ ______ obstruction

upper GI bleed perforation and/or penetration gastric outlet obstruction