1. epigastric pain 1 to 2 hrs after eating 2. pain 2 to 5 hrs after eating

1. gastric ulcer 2. duodenal ulcer

L5: PUD Flashcards by Jhannel Wu

Defined as a circumscribed loss of the
mucous membrane of the stomach or
duodenum or of any other part of the GI
system exposed to gastric juices
containing acid and pepsin.

PUD

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Marked by ulcers or sores located in the
mucus membrane of the stomach (gastric
ulcer) or duodenum (duodenal ulcer)

PUD

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ulcers in PUD extends deeper into the…

muscularis mucosa

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occur in stomach

gastric ulcers

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occur in duodenum

duodenal ulcer

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epigastric pain 1 to 2 hrs after eating
pain 2 to 5 hrs after eating

gastric ulcer
duodenal ulcer

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Can cause hematemesis (vomiting of blood)
or melena (blood tarry stool)

gastric ulcer

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Can cause melena or hematochezia
(presence of blood in the stool)

duodenal ulcer

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Can cause gastric carcinoma (mostly in the
elderly)

gastric

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Heartburn, chest discomfort are less
common but may be seen

duodenal

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Heartburn, chest discomfort and early
satiety are commonly seen

gastric

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Pain may awaken patient during the night
(nocturnal pain)

duodenal

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less severe gi bleeding

h pylori induced

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rare
condition in which one or more tumors
(gastrinoma) are formed in the
pancreas, which can secrete the
hormone gastrin that stimulates the
production of gastric acid

Zollinger-Ellison syndrome

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DISEASES AND MEDICAL CONDITIONS
ASSOCIATED WITH CHRONIC PEPTIC
ULCER

• 2/3 gastric ulcer patients are infected with
H. pylori
• Considered Class 1 Carcinogen (gastric
cancer)
NSAIDS
o Cirrhosis
o Chronic renal failure
o COPD
o Cardiovascular disease
o Organ transplantation

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h pylori, enzymes

urease
protease
oxidase

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most common cause of PUD

h pylori

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PGE2 helps in the secretion of what

mucus and bicarbonates

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Superficial mucosal damage consisting of
petechiae (intramucosal hemorrhages)
within minutes of ingestion, and progress to
erosions with continued use.

nsaids

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Impairs ulcer healing and may be
associated with ulcer-related GI
complications.

cig smoking

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Stress increases cortisol, which stimulates
secretion of …

gastric acid

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cause of ulceration

Because of imbalance between
aggressive (acid, pepsin, bile salts)
and protective factors (mucus,
HCO3-)

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Secreted from the parietal cells in the body
of the stomach

hcl

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duodenal ulcer hcl secretion is increased or decreased

increased

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hcl secretion in gastric ulcer increases or decreases

decreased normal secretion

3 receptors in the stomach

neurocrine endocrine paracrine

what is released and what is the receptor neurocrine

Ach m3 receptors

what is released and what is the receptor endocrine

gastrin cholecystokinin B receptor

what is released and what is the receptor paracrine

histamine h2 receptor

involved in the inhibition of the secretion of hydrochloric acid

somatostatin and PGE2

_ & _ will inhibit secretion of gastrin and hydrochloric acid

Secretion of somatostatin and cholecystokinin

Exhibits CIRCADIAN RHYTHM

basal stimulated

Accounts for the characteristic nighttime awakening with peptic ulcer pain

basal stimulated

why is it more effectve to take h2 blockers or ppis at night

Highest gastric acid secretion = night

causes inflammation and increases development of PUD

CagA- Cytotoxin-associated gene protein A

induces apoptosis and disruption of the cellular pathways

VacA- Vacuolating cytotoxin

anorexia is more common at

gastric ulcer (than duodenal ulcer)

COMPLICATIONS OF PUD

1. bleeding 2. perforation 3. Obstruction from edema or scarring 4. intractable pain

second most common ulcer-related complication

perforation

occur with duodenal ulcer

Obstruction from edema or scarring

diagnostic procedure of choice for suspected peptic ulcer

FIBER-OPTIC UPPER ENDOSCOPY

helps visualize ulceration and assess if there is bleeding

FIBER-OPTIC UPPER ENDOSCOPY

test for h pylori

- endoscopic test -nom-endoscopic test

endoscopic tests for h pylori

1. histology 2. culture 3. biopsy urease 4. pcr

non endoscopy test for h pylori

UBT fecal antigen test serological test

Gold Standard - >95% sensitivity and specific

histology

Culturing of sample in a media - Sensitivity testing - 100% specific

culture

Test of choice at endoscopy

biopsy urease

Generates ammonia to produce color change - Rapid results (within 24 hours)

biopsy urease

Tests the genetic material of the bacteria

pcr

considered a research technique

pcr

the most accurate noninvasive test (95% sensitivity)

ubt

identifies H. pylori antigen in stool by enzyme immunoassay using polyclonal anti H. pylori antibody

fecal antigen test

confirms post treatment eradication of h pylori

fecal antigen test

blood test to detect antibodies againt H.pylori

serological test

Quantitative; less sensitive and specific than endoscopy.

lab based serological test

Qualitative; quick (within 15 minutes).

office based serological test

NOT used for post-treatment eradication

serological test

high doses are required for healing: 40 mEq of base seven times daily

antacids

Now, a non-Rx remedy for heartburn and dyspepsia.

antacids

FDA requirement if acid neutralizing capacity

should be greater than or equal to 5 mEq per dose.

rapid onsent antacids

Mg(OH)2, MgO, CaCO3

slow onset antacids

Mg trisilicate and aluminum compounds

antacids ideal dosing interval

1 and 3 hours after meals and at bedtime

antacids that should be avoided for px with heartfailure

Heart failure = excess sodium intake (inc. toxicity) (**should avoid systemic antacids**)

antacids to be avoided for px with renal failure

Renal failure = **should not use magnesium or aluminum containing antacids**

magnesium and aluminum containing antacids causes what to px with renal failure

mg or al contaminf = **hypermagnesemia** nahco3 = **systemic alkalosis**

Rapidly reacts with HCL to produce CO2 and NACl

sodium bicarbonate

Absorbed systematically and should not be used for long-term treatment

sodium bicarbonate

sodium bicarbonate produces…

Produces distension and belching (can cause flatulence and enlargement of stomach)

ANC of nahco3

1 gram = 12 mEq

Partially absorbed from the gastrointestinal tract and have some systemic effects

calcium carbonate

Reacts slowly with HCl and can form CO2 and CaCl, causing belching

calcium carbonate

May stimulate gastrin release and thereby cause rebound acid production

calcium carbonate

CI in calcium carbonate

renal disease

ADR of calcium carbonate

Hypercalcemia, Alkalosis, Renal failure (milk-alkali syndrome)

Reacts slowly with HCl, forming magnesium chloride

Mg(OH)2

DOES not produce CO2, therefore does not cause belching and gastric distention

Mg(OH)2

Not absorbed in the GIT therefore produces no systemic effects

magnesium hydroxide

antacid that can be used for long term therapy

Mg(OH)2

May produce osmotic diarrhea (common SE)

Mg(OH)2

Has no systemic effects and no belching, and causes constipation, hypophosphatemia and osteomalacia

Al(OH)3

prolonged aluminum use

- phosphate depletion - reduce calcium absorption: Osteoporosis, Osteomalacia, Neurotoxicity

Used to defoam gastric juice to decrease the incidence of gastroesophageal reflux

simethicone

h2ra are cleared by a combination of

- hepatic metabolism - glomerular fitration - renal tubular secretion

Suppress basal and meal-stimulated acid secretion

h2ra

most potent at 20mg

famotidine

least potent ; higher dose needed

cimetidine

used as prophylactic

h2ra

h2ra are taken when

before meals

preferred drug for erosive esophagitis

If with erosive esophagitis, healing is only at 50%, PPIs are more preferred.

H2 blockers has no effect if?

NSAID-induced

Bioavailability is reduced by antacids

cimetidine

• Decreases the absorption of Ketoconazole

cimetidine

cimetidine adverse effects

• Thrombocytopenia • Gynecomastia and Impotence o (androgen receptor antagonist) • Mental confusion in the elderly • Low incidence of mild GI upset, headache

5 – 10X more potent than cimetidine • Does not bind to androgen receptor (no gynecomastia)

ranitidine

Secreted in milk therefore it should not be given in lactating mothers

ranitidine

Low incidence of headache and cutaneous rash

ranitidine

hepatotoxic

ranitidine

Tachyphylaxis compromise its long-term use

famotidine

mild cardiotoxic h2ra

famotidine

is famotidine for long term use?

As effective as ranitidine and may be administered once daily

nizatidine

like ranitidine, this drug may produce hepatotoxicity

nizatidine

doesnt affect cyp

famotidine and jizatidine

One of the most widely prescribed drugs.

ppi

ppis are all?

prodrugs

ppi with the highest bioavailability

esomeprazole amd lansoprazole

fastest onset of action

omeprazole

when should ppis ne taken

Taken 30 to 60 mins before meals (usually before breakfast)

days after full effect of ppi

3-4days

Undergo rapid first-pass and systemic hepatic metabolism (needs dose adjustment) and have negligible renal clearance

ppi

erosive gerd

OD ppi bid for 3 months for extraesophageal complic of reflux disease

for non erosive gerd

h2ra or ppis prn

heals more than 90% of duodenal ulcers within 4 weeks

ppi

ppi heals more than 90% of gastric ulcers within 6 to 8 weeks

PEPTIC ULCER (NSAID) tx

OD PPI or H2 antagonists + withdraw NSAID

PEPTIC ULCER (H. PYLORI-ASSOCIATED) tx

Most effective regimen: 2 antibiotics + 1 PPI (triple therapy)

14 day regimen for h pylori pud

1 PPI bid, **clarithromycin 500 mg bid, and 1 g Amoxicillin or 500 mg Metronidazole bid** o After completion = PPI is still continued OD 4 – 6 weeks** (for ulcer healing)**

PREVENTION OF STRESS-RELATED MUCOSAL BLEEDING tx

Omeprazole orally via NGT

Generally safe but can impair Vit b12 absorption in long term use

adr of ppi

May cause increased Gastrin levels (Hypergastrinemia, may return to normal after 1 month of discontinuation)

ppi

inhibits metabolism of warfarin, diazepam, phenytoin

omeprazole

inhibits metabolism of diazepam

esomeprazole

enhances clearance of Theophylline

lansoprazole

Given as delayed release capsule because of acid lability

omeprazole

omeprazole ci

pregnant

Acid labile and administered as an enteric coated tablet

lansoprazole

• Prodrug that requires protonation for activation

lansoprazole

anticholinergic drugs

Propantheline, Isopropamide and Scopolamine

Binds to ulcers (up to 6 hrs) • Protects ulcerated areas from further damage and promotes healing

sucralfate

stimulates mucosal production of prostaglandins and inhibits pepsin

sucralfate

sucralfate is taken when

empty stomach 1hr before meals

avoided when using sucralfate

PPIs, H2 antagonists, and antacids acid is needed for activation

PROSTAGLANDIN E1 ANALOGUE

misoprostol

Has both inhibitory and mucosal protective properties

misoprostol

misoprostol is given daily __x

3-4x

INCREASES mucus and bicarbonate secretion by the gastric epithelium by increasing epithelial regeneration and by enhancing mucosal blood flow, thus **enhancing mucosal protection**

misoprostol

binds to a prostaglandin receptor on parietal cells, reducing histamine-stimulated cAMP production and causing modest acid inhibition.

misoprostol

Coats ulcers and erosions, creating a protective layer against acid and pepsin.

colloidal bismuth compounds

Reduces stool frequency and liquidity in acute infectious diarrhea

colloidal bismuth compounds

Has direct antimicrobial effects and binds enterotoxins beneficial for H. pylori infections

bismuth…

should be used for only short periods and should be avoided in patients with renal insufficiency.

bismuth agents

Synthetic derivative of glycyrrhizic acid

carbenoxolone

• Heals both gastric and duodenal ulcers

carbenoxolone

AE of carbenxolone

Aldosterone effect (can cause sodium and water retention, therefore leading to **HTN and hypokalemia)**

Impaired pancreatic secretion may cause steatorrhea (fatty stool), which can lead to fat- soluble vitamin deficiency (vit ADEK).

octreotide

octreotide adrs

hypothyroidism bradycardia acute cholecystitis

Recommended first line option particularly for those patients who are allergic to penicillin or clarithromycin.

bismuth salicylate metro tera ppi/h2ra

10 days anti / sequential therapy

1st 5 days - ppi - amoxicillin 2nd 5 days - ppi - clarithro - metro/tini

CONCOMITANT THERAPY: HYBRID THERAPY

1st 7 days - ppi - amoxicillin 2nd 7 days - ppi - amoxi - claritho - metro/tini

L5: PUD Flashcards

(151 cards)