Peptic Ulcer Disease

Question 1

Kinds of ulcers

Answer 1

Gastric and duodenal

Question 2

What does ulcer severity tell you?

Answer 2

The deeper the ulcer, the more severe the damage is

Question 3

How can you determine the ulcer severity?

Answer 3

ENDOSCOPY

Question 4

Main symptom of PUD

Answer 4

DYSPEPSIA

Question 5

PUD’s association with food

Answer 5

Duodenal ulcers- food helps the pain

Gastric ulcer- food makes it worse

Question 6

Patients with duodenal ulcers will describe what symptom?

Answer 6

Pain that wakes them up at midnight-3 AM

Question 7

The #1 cause of PUD is due to what?

Answer 7

H. pylori bacteria

Question 8

H. pylori tends to cause what kind of ulcers?

Answer 8

Duodenal ulcers

Question 9

Features of H. pylori

Answer 9

Spiral shape with flagellum
Adherence pedestals
Protective mechanisms against stomach acid

Question 10

Protective mechanisms of H. pylori

Answer 10

Convert urea to ammonia and bicarb
Produces lipases and proteases to degrade mucus later
Toxin production
Induces inflammatory immune response

Question 11

Diagnosis methods of PUD

Answer 11

Endoscopy and blood tests

Question 12

Tests used to determine eradication of H. pylori infection

Answer 12

Breath tests and fecal antigen tests

Question 13

What class of drugs is the #1 cause of drug-related toxicity in the US?

Answer 13

NSAIDs

Question 14

How can NSAIDs cause ulcers?

Answer 14

Decreases prostaglandin effects
Epithelial cell turnover
Weak acids crossing into epithelial cells and getting trapped

Question 15

Risk factors for NSAID-induced PUD

Answer 15

>65 years
Past history of an ulcer or PUD
Concomitant steroid use with NSAID (mostly non-selective NSAIDs)
Anticoagulants (warfarin, DOACs)
Antiplatelets (ASA, Plavix, P2Y12is)

Question 16

How many risk factors do you need to start on PPI prophy for NSAID-induced PUD?

Answer 16

≥1

Question 17

Diagnosis of NSAID-induced PUD

Answer 17

Patients describing dyspepsia symptoms
NSAID taking history
ENDOSCOPY

Question 18

Alcohol use and PUD

Answer 18

Usually causes superficial gastritis and nothing life-threatening

Question 19

What patients are at risk for stress-related mucosal bleeding due to illness PUD?

Answer 19

Patients who are in the hospital ICU with sepsis, mechanical ventilation, etc.

Question 20

Altered defense mechanisms in patients with critical illness PUD

Answer 20

No acid in stomach
Decreased blood flow to GI tract due to hypotension
Release of damaging mecanisms

Question 21

Major risk factors for critical illness PUD

Answer 21

Respiratory failure (mechanical ventilation for ≥48 hours or planning to be for ≥48h)
Coagulopathy: INR >1.5 or platelets <50

Question 22

How many major risk factors do you need to be at risk for critical illness PUD?

Answer 22

1

Question 23

Minor risk factors for critical illness PUD

Answer 23

Sepsis, hypotension/requiring pressors, history of GI bleeding, use of high dose steroids

Question 24

How many minor risk factors do you need to be at risk for critical illness PUD?

Answer 24

≥2

Question 25

What disease can also cause critical illness PUD?

Answer 25

Zollinger Ellison Syndrome (gastrin-producing tumor)

Question 26

Symptom of Zollinger-Ellison Syndrome

Answer 26

Diarrhea

Question 27

PPI dosing in Zollinger-Ellison Syndrome

Answer 27

Dosed q8-12h!

Question 28

When to suspect upper GI bleeding

Answer 28

Haematemesis, melina Patients who use NSAIDs History of PUD

Question 29

Presentation of UGIB

Answer 29

Vomiting blood, jet black stools, epigastric pain (dyspepsia), high heart rate, low blood pressure, low hemoglobin and hematocrit

Question 30

Treatment of UGIB

Answer 30

IV bolus of LR or NS STAT Blood products for plasma expansion (packed RBCs) Supplemental O2 Fresh frozen plasma for reverse anticoagulation Epinephrine, cauterization 80mg bolus of pantoprazole or esomeprazole, then 8mg/hr infusion x72 hours OR IV pantoprazole 40mg IV BID

Question 31

Target Hgb

Answer 31

7

Question 32

Target Osat

Answer 32

92%

Question 33

Complication of PUD

Answer 33

GI BLEEDING

Question 34

Treatment goals of PUD

Answer 34

Relieve pain, heal ulcer, prevent recurrence, eliminate H. pylori if it's the cause

Question 35

How long should H. pylori treatment last?

Answer 35

10-14 days

Question 36

H. pylori treatment: triple therapy

Answer 36

PPI of choice BID Clarithromycin 500mg BID Amoxicillin 1g BID

Question 37

H. pylori treatment: bismuth quadruple therapy

Answer 37

PPI of choice BID Bismuth subsalicylate or subcitrate QID Tetracycline 500mg QID Metronidazole 250mg QID or 500mg TID

Question 38

H. pylori treatment: levofloxacin triple therapy

Answer 38

PPI of choice BID Levofloxacin 500mg QD Amoxicillin 1g BID

Question 39

When to use bismuth quad therapy

Answer 39

FIRST-LINE!

Question 40

When to use levofloxacin triple therapy

Answer 40

If quad therapy fails

Question 41

What to use in patients with a PCN allergy but need H.pylori treatment

Answer 41

Bismuth quad therapy, can also use metronidazole for the ampicillin instead in triple therapy

Question 42

H. pylori eradication tests

Answer 42

Wait 4 weeks after treatment is done, then use urea breath test or fecal antigen test

Question 43

What happens if there's no eradication?

Answer 43

Treatment continues | If triple therapy was used the first time, go to bismuth quad therapy

Question 44

Treatment for NSAID-induced PUD

Answer 44

PPI for 4 weeks, but can extend to 8 weeks or longer if NSAID use continues

Question 45

Prevention of NSAID-induced PUD

Answer 45

Switch to APAP if possible, switch to selective COX-2 NSAID if possible (celecoxib (Celebrex)), add on PPI as prophy, add prostaglandin analog (misoprostol)

Question 46

Treatment for NSAID-induced PUD in patients that require both an antiplatelet and NSAID

Answer 46

Use celecoxib (Celebrex) when possible, add PPI to regimen

Question 47

Prophylaxis for stress ulcer

Answer 47

H2RAs! Ranitidine (Zantac)

Question 48

Duration of prophy for stress ulcer

Answer 48

Continue until risk factors are gone

Question 49

Management of ASA or P2Y12i (secondary prevention)

Answer 49

Evaluate risk vs. benefit --> risk of having a post-stent cardiac event outweighs the GI bleeding risk Make sure bleeding stops, check hemoglobin multiple times a day. Restart antiplatelet within 1-3 days after hemoglobin stabilizes

Question 50

What happens if a patient is taking ASA with no cardiac history?

Answer 50

D/C the ASA because the risk of GI bleeding outweighs the benefit

Question 51

Selective NSAIDs

Answer 51

Celecoxib, meloxicam, etodolac, nabumetone