GERD and PUD

Question 1

How is GERD diagnosed?

Answer 1

Easiest way is to just do a trial of a PPi like omeprazole. It’s both sensitive and specific

Question 2

What are “alarm symptoms” for GERD (AKA indications for an endoscopy)?

Answer 2

1. Dysphagia/Food sticking (rule out stricture or cancer)
2. Iron deficiency anemia
3. Wt loss
4. Jaundice
5. Palpable abdominal mass
6. Odynophagia
7. New onset and age >55 yrs old

Question 3

When would you ever use ambulatory esophageal pH monitoring to diagnose or evaluate GERD?

Answer 3

If diagnosis is uncertain or if they don’t respond to Ppi

Question 4

What are the symptoms of GERD other than burning chest pain?

Answer 4

Pain worse with lying down or bending forward

Pain that is non-exertional

Question 5

Which ulcers should be biopsied?

Answer 5

All gastric ulcers, even if appear benign. No duodenal ulcers, even if look malignant.

Question 6

When do you test for H. Pylori in an ulcer?

Answer 6

All patients with active ulcers, plus those with inactive ulcers who have never been treated for H pylori

Question 7

What condition make a rapid urease test for H. Pylori less reliable?

Answer 7

Taking a ppi within 2 weeks, or antibiotic within 4 weeks, of the test reduces sensitivity by 25%

Question 8

What is triple therapy for an ulcer and when is it used?

Answer 8

Ppi + amoxicillin 1 g BID+ clarithromycin 500 mg BID

Used if proven infection with H Pylroi

Question 9

What are the 2 most common causes of PUD?

Answer 9

1. NSAIDs
2. H pylori

These account for >90% of cases

Question 10

What symptoms of PUD would lead you to suspect zollinger-ellison syndrome and therefore want to measure serum gastrin levels?

Answer 10

1. multiple PEPTIC ulcers
2. ulcers in unusual locations
3. severe esophagitis
4. fat malabsorption

Question 11

What are indications to start metoclopramide?

Answer 11

Early satiety, nausea, normal upper endoscopy, and absence of other common causes like NSAID use

^ALL must be present! So don’t start it without a normal upper endoscopy

Question 12

What is functional dyspepsia?

Answer 12

The Rome II committee defined functional dyspepsia as the presence of abdominal pain or discomfort centered in the epigastrium and present for at least 12 weeks over the last 12 months, which cannot be explained by upper gastrointestinal investigation

Question 13

What are Cameron lesions?

Answer 13

linear gastric ulcers in the hiatial hernia sac. Seen in 5% of pts with hiatial hernias. Can cause chronic blood loss.

Question 14

What is next best step for someone with persistently + FOBT but normal upper endoscopy and other labs?

Answer 14

Repeat upper endoscopy (will find a source in 30-60% of repeat cases). Then repeat colonscopy. Then capsule endoscopy.

Question 15

How should you manage someone that comes in with severe hematemesis?

Answer 15

• Empiric omeprazole IV (not oral, obviously!)
• Normal saline
• RBC infusion

Question 16

Once a patient with severe hematemesis is stabilized with NS and RBC, what is the next step?

Answer 16

Do an upper endoscopy to provide a diagnosis/prognosis AND treat an ulcer while you’re in there if its bleeding. I guess a bleeding ulcer is more likely than bleeding esophageal varices (I think varices only occur in people with CLEAR cirrhosis like ascites, etc), and thats why you do endoscopy to check for it.

Question 17

What is the % risk of rebleeding for an ulcer WITH A VISIBLE VESSEL or that has ALREADY BLEDl?

Answer 17

50%, unless you go patch it up with upper endoscopy

Question 18

What is the % risk of rebleeding for an ulcer with a clean base?

Answer 18

5%

Question 19

What is the first treatment step for acute variceal hemorrhage?

Answer 19

RBC transfusion

Question 20

When is platelet transfusion indicated for treatment of acute variceal hemorrhage?

Answer 20

Platelet count

Question 21

What is the second treatment step (after RBC transfusion) for acute variceal hemorrhage?

Answer 21

1. Urgent esophagogastroduodenoscopy, to ligate esophageal varices and prevent early rebleeding.
2. IV octreotide to reduce portal vein flow

Question 22

When would aerteriography be used to stop bleeding from a peptic ulcer or tumor?

Answer 22

Patient is actively bleeding and endoscopic therapy didn’t work (either because the thing kept bleeding, or because it didn’t show anything because too much blood)

Question 23

When is nadolol used for esophageal varices?

Answer 23

For primary and secondary PREVENTION of variceal bleeding. Not as acute therapy

Question 24

Options to treat h pylori GERD

Answer 24

“Triple therapy” for 10-14 days (70-85% eradication rate):

PPI standard dose twice daily (esomeprazole is dosed once daily)
Amoxicillin 1 gram twice daily
Clarithromycin 500 mg twice daily
“Quadruple therapy” for 10-14 days (75-90% eradication rate):

PPI standard dose once or twice daily (OR ranitidine 150 mg twice daily)
Metronidazole 250 mg four times daily
Tetracycline 500 mg four times daily
Bismuth subsalicylate 525 mg four times daily

Question 25

screening for h pylori

Answer 25

serology testing is the best. Cant use urease testing while on ppi, and its more expensive.

fecal occult blood testing can be used second line to confirm

Question 26

What tests can you run to confirm the eradication of H. Pylori?

Answer 26

fecal antigen test + urea breath test

Question 27

why is persistence of heartburn symptoms even after antacids concenring?

Answer 27

because it suggests PUD, which is worse than GERD (bc its an ulcer… can bleed etc)

Question 28

What do you do if a GERD trial doesnt work?

Answer 28

If stopped ppi >2 weeks ago or antibiotics >4 weeks ago: Urea breath test

If ppi or antibiotics could cloud breath test: serology for h pylori antigen

If alarm symptoms (dysphagia, anemia, >55 yrs old, wt loss, jaundice, palpable mass): Endoscopy

Question 29

What are indications for re-testing for H pylori after triple therapy to prove eradication?

Answer 29

1. Patients with an H. pylori-associated ULCER
2. Persistent symptoms despite appropriate therapy for H. pylori
3. Patients with H. pylori-associated MALT lymphoma
4. History of resection for early gastric cancer
5. Patients planning to resume chronic NSAID therapy (ex: SLE patients)