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GERD, Ulcer, GI Bleed Flashcards

1
Q

Alarm symptoms of GERD

A

Dysphasia (difficulty swallowing)
Odynophagia (painful swallowing)
Bleeding
Weight loss
Choking
Chest Pain
Epigastric mass

Require referral for invasive testing (endoscopy)

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2
Q

Nonpharm treatments for GERD

A

ACG guidelines cite insufficient evidence, so only in these populations:

1) dietary modifications to avoid trigger foods; avoid eating 2-3 hours before bed
2) Weight loss (if overweight/obese)
3) Avoid tobacco, smoking
4) Elevate head of bed if nocturnal symptoms present

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3
Q

First line GERD treatment for esophageal erosion; severe symptoms

A

“Step down” - start @ max then decrease therapy

Therapeutic PPI

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4
Q

First line GERD treatment for intermittent symptoms (<2x/week)

A

OTC Antacids

Not appropriate if esophageal erosions present
Can also be used as breakthrough if already on PPI or H2RA

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5
Q

Aluminum and calcium ADR in antacids

A

constipation

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6
Q

magnesium ADR in Antacids

A

diarrhea

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7
Q

gaviscon

A

antacid containing alginic acid which forms viscous layer on top of gastric contents to prevent reflux

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8
Q

Meds that may have reduced absorption from increased pH from all antacids

A

Azoles (ketoconazole, itraconazole)
Iron
Atazanavir
Rilpivirine
Ledipasvir
Velpatasvir
Nelfinavir

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9
Q

Renal dosing for H2RA

A

Cimetidine: severe impairment, 300bid

Famotidine:
30-60ml/min: 20-40mg daily or 40mg every other day
<30: 10 or 20mg daily or 20mg every other day

Nizatidine:
20-50: 150mg daily
<20: 150 every other day

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10
Q

H2RA place in therapy

A

on demand dosing for mild-moderate GERD

less effective than PPI in erosive esophagitis

Long term use may cause tachyphylaxis

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11
Q

PPIs that can be used in NG tube

A

Omeprazole
Esomeprazole
Lansoprazole

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12
Q

Acute interstitial nephritis and PPIs

A

Shorten duration of PPI
If long term use: annual renal fxn monitoring, dose reduction, de-prescribing

AIN may recur with PPI rechallenge

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13
Q

Risk of fracture with PPI

A

Concern for fracture is not a reason to NOT prescribe PPI (unless other risk factor for hip fracture)

If have osteoporosis, may remain on PPI – ensure enough vit D and calcium, exercise, BMD screens

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14
Q

Vitamin deficiencies with PPIs

A

hypomagnesemia
iron deficiency
B12 deficiency

reevaluate need for PPI; supplement

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15
Q

Cdiff and PPI

A

Reevaluate need for PPI

If pt on PPI with diarrhea not improving, test for Cdiff

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16
Q

CAP and PPI

A

Short term use may increase risk

Assess vaccine status

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17
Q

PPI and methotrexate

A

PPI may inhibit excretion of high dose IV methotrexate, resulting in MTX toxicity

Do not give combo of PPI + high dose MTX. Hold PPI x2 days before AND after MTX administration

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18
Q

Promotility agents and GERD

A

Recommend against unless evidence of gatroparesis

Metoclopramide (dopamine antagonist)
Bethanecol (cholinergic agonist - off label)

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19
Q

Metoclopramide BBW

A

Irreversible tardive dyskinesia

20
Q

Sucralfate place in therapy for GERD

A

routine use for pregnancy only

21
Q

Gastric Vs Duodenal ulcer

A

Eating:
worsens symptoms (gastric)
improves (duodenal)

Both can be caused by H pylori or NSAID use

22
Q

NSAID Risk factors for ulcer

A

> 65 y/o
High dose NSAID therapy (ibu >2400mg/day, naproxen 1000mg/day)
History of uncomplicated ulcer
Concurrent use of low-dose aspirin, steroids, anticoagulants

Moderate risk if 1-2 factors
High risk if >2 factors

23
Q

Serologic H pylori test

A

QuickVue, H. pylori gII, FlexSure HP

noninvasive test to detect IgG to H pylori

Cannot distinguish between active infection and past exposure

Cannot be used to test for eradication, because antibodies persist after treatment

24
Q

Urea breath test for H pylori

A

UBT, BreathTek UBT, PYtest

Noninvasive test to detect exhalation of radiolabeled CO2 after ingestion of 13c which results in CO2

High sensitivity and specificity = use for diagnosis AND eradication

False negatives caused by recent antibiotic or PPI use; wait 4 weeks after completing of therapy to test

25
Stool antigen test for H pylori
Premier Platinum HpSA; ImmunoCard STAT! HpSA Antibody test to detect H pylori in stool Decent sensitivity and specificity (upper 80s) = diagnosis AND eradication False negatives can be caused by bismuth, abx, ppis -- wait 4 weeks after treatment
26
Endoscopy for H pylori
Invasive test - used less often (cost, time, invasive) Rapid urease test used on biopsy to detect presence of H pylori D/c ppi 1 week before endoscope
27
First line H pylori treatment (clarithromycin triple, bismuth quadruple)
Clarithromycin triple x14 days: -PPI (standard or double dose) BID -Amoxicillin 1000mg BID or metronidazole 500mg TID -Clarithromycin 500mg BID Bismuth Quadruple x10-14 days: -PPI standard dose BID -Bismuth subsalicylate 300mg QID or bismuth subcitrate 120-300mg QID -Metronidazole 250mg QID or 500mg TID-QID -Tetracycline 500mg QID Bismuth quadruple if clarithromycin resistance high, pt has prior macrolide exposure, or pcn allergy
28
Salvage therapy for H pylori
Bismuth quadruple therapy or Levofloxacin triple therapy x10-14 days: -PPI standard BID -Levofloxacin 500mg daily -Amoxicillin 1000mg BID
29
Concomitant H pylori therapy
-PPI standard BID -Clarithromycin 500mg BID -Amoxicillin 1000mg BID -Metronidazole or tinidazole 500mg BID 10 days Appears as effective as clarithromycin triple therapy but not validated in North America
30
Vonoprazan
Newly approved treatment for H pylori but not yet included in guidelines Vonoprazan 20mg BID Amox 1000mg BID Clarithromycin 500mg BID 10 days OR Vonoprazan 20mg BID Amoxicillin 1000mg TID 14 days
31
Indicator of high CV risk before starting NSAIDs
on aspirin for primary prevention
32
High risk NSAIDS
Piroxicam Indomethacin Ketorolac
33
Moderate risk of ulcer on NSAID
NSAID + PPI or misoprostol Same if low or high CV risk. Prefer naproxen in high CV risk
34
Low risk of ulcer on NSAID
low CV risk: NSAID at lowest dose high CV risk: naproxen _ PPI or misoprostol
35
High risk of ulcer on NSAID
low CV risk: COX2 inhibitor + PPI or misoprostol high CV risk: avoid NSAID, avoid COX2 inhibitors
36
Gatroprotective therapy for NSAID + antiplatelet
PPIs preferred -Prescribe if GI risk factors requiring NSAIDs + low dose aspirin or low-dose aspirin alone -Prescribe if receiving any anticoagulant + aspirin -If warfarin added to aspirin and P2Y12, aim for INR 2.0-2.5 **Aspirin plus PPI is superior to clopidogrel for GI bleed risk**
37
Misoprostol limitation for gastroprotection
dosing frequency diarrhea, abdominal pain ADRs
38
COX2 inhibitors and CV risk
Associated with thrombotic events Why? Idea is that COX2 reduces prostacyclin production but COX1 still produces thromboxane A = prothrombotic state Daily doses of 400-800mg were seen with ~3x risk for fatal/nonfatal MI (dose related risk)
39
Musculoskeletal pain & CV disease or high risk treatment approach
1) topical NSAID 2) APAP, aspirin, tramadol, short-term narcotic 3) nonacetylated salicylates 4) NonCOX2 selective NSAIDs 4) Celecoxib is last resort
40
Risk of GI bleed outweighs CV risk
Choose ibuprofen, etodolac, diclofenac, celecoxib
41
Risk of CV risk outweighs GI bleed risk
avoid COX2 inhibitors
42
Upper GI bleed Management
1) Fluid resuscitation - give before blood (Hgb <7) 2) Stratify risk for death, recurrence, 3) Endoscopy within 24 hours 4) PPI
43
PPI for upper GI bleed
Pre-endoscopy: 80mg IVB, then 8mg/hr IV infusion. does NOT reduce mortality, surgery, rebleed. Post endoscopy: 80mg IVB then 8mg/hr for 72 hours OR 80mg IVB followed by 40mg PO or IV 2-4x daily x3 days -Given after endoscopy = decrease in rebleeding, mortality, need for surgery
44
H2RA or octreotide for upper GI bleed
Not recommended
45
Independent risk factors for SRMD
Ventilated >48 hours Coagulopathy (INR >1.5, plt <50) Thermal injury >35% BSA Severe head or spinal cord injury GI bleed within past year Multiple trauma Perioperative transplant period Low intragastric pH Major surgery (>4 hrs) Acute lung injury
46
Risk factor for SMRD (>=2 of following)
Sepsis ICU >1 week Occult bleeding High dose steroids (=250mg hydrocortisone) Hepatic failure Acute renal insufficiency Hypotension Anticoagulation
47
SMRD Prevention
PPI similar in efficacy & safety to H2RA PO or IV similar efficacy Cimetidine only H2RA with FDA approval for SRMD but all can be used

BCPS (40 decks)

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