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PUD Flashcards

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1
Q

What is PUD?

A

ulceration of the mucosa anywhere in the GI tract exposed to acid and pepsin

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2
Q

Which PUD form is most common?

A

Duodenal > Gastric

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3
Q

What is PUD caused by?

A
  1. Helicobacter pylori (HP)
  2. Chronic NSAID use
  3. Stress-related mucosal damage
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4
Q

Does smoking improve or worsen PUD?

A

worsen

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5
Q

What is the mechanism of stress-related mucosal damage?

A
  1. decreased mucosal defense mechanisms
  2. emotional stress –> increased smoking/ NSAID use –> increased risk of PUD
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6
Q

What is the pathogenesis of PUD?

A

Imbalance between aggressive factors and mechanisms that maintain mucosal integrity

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7
Q

What is the most common cause of duodenal (~95%) and gastric ulcers (~80%)?

A

H. pylori

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8
Q

How is H.pylori spread?

A
  1. fecal to oral route
  2. oral to oral route
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9
Q

What are possible mechanisms for H.pylori induced mucosal damage?

A
  1. catalyzes urea–> ammonia–> erodes mucosal barrier and epithelial damage
  2. production of cytotoxins
  3. production of mucolytic enzymes
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10
Q

How likely are ulcers caused by chronic NSAID use?

A

Duodenal (2-5%) and gastric (10-20%)

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11
Q

What are mechanisms for NSAID induced ulcers?

A
  1. inhibit cyclooxygenase activity–> decrease prostaglandin production
  2. decrease gastric and mucosal blood flow
  3. decreased mucus and bicarbonate secretion
  4. decreased cellular replication and repair
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12
Q

Who is more likely to experience major complications due to NSAIDs?

A
  1. > 60 y/o
  2. Hx of PUD
  3. High dose/ multiple NSAIDs or low dose ASA daily,
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13
Q

What medications administered with NSAIDs will increase risk of PUD?

A
  1. corticosteroids
  2. anticoagulants
  3. oral bisphosphonates
  4. antiplatelet agents
  5. SSRIs
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14
Q

What NSAID is the most ulcerogenic?

A

Aspirin

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15
Q

What is the first presentation of NSAID-induced ulcers?

A

bleeding/ perforation

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16
Q

What are common presentations of gastric ulcers?

A
  1. pain is not predictable
  2. food can cause pain
  3. weight loss
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17
Q

What are common presentations of gastric ulcers?

A
  1. pain more likely to follow consistent pattern
  2. food often eases pain and returns in 1-3 hours
  3. noctural epigastric pain
  4. nonspecific dyspepsia
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18
Q

What are the major complications of PUD?

A
  1. bleeding
  2. perforation
  3. death from acute bleeding
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19
Q

What lab tests are used to determine H.pylori-induced ulcers?

A
  1. Rapid Urease Test (CLO test)
  2. serologic antibody test
  3. Urea Breath Test (UBT)
  4. Fecal Antigen Test (FAT)
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20
Q

How is the Rapid Urease test done?

A

Mucosal biopsy–> urea rich medium with pH sensitive dye–> HP urease will produce NH3, increase the pH and cause a color change

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21
Q

How does a serologic test determine HP infection?

Study These Flashcards
A

Detects IgG to HP in serum

22
Q

What are problems with the serologic test?

Study These Flashcards
A

Can’t distinguish active infection from past exposure because antibodies persist for up to 5 years

23
Q

How does the Urea Breath Test (UBT) work?

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A

Patient ingests molecule with C 13/14–> H. pylori urease produces CO2 13/14–> CO2 13/14 is in blood and can be detected in breath

24
Q

How does the Fecal Antigen Test (FAT) work?

Study These Flashcards
A

polyclonal antibody test detects presence of HP in the stool

25
Patients recently taking antibiotics & bismuth compounds (~4 weeks), or anti-secratory agents (~2weeks) can cause false positives in what test?
UBT
26
What tests are used for initial screening for infection?
serologic, UBT, FAT
27
What tests are used to determine eradication?
UBT and FAT
28
How long after treatment is completed do you need to wait before confirming eradication?
4 weeks
29
What are 1st line therapies for HP eradication?
1. Bismuth-based quadruple therapy 2. Standard Triple Therapy 3. Concomitant therapy
30
What is used for Standard Triple Therapy?
Amoxicillin + Clarithromycin + PPI Penicillin allergy: Metronidazole
31
When is Standard Triple Therapy 1st line?
Clarithromycin resistance rates <15% and patient has NEVER taken a macrolide antibiotic
32
What is used for Bismuth-based Quadruple Therapy?
Tetracycline + Metronidazole + Bismuth subsalicylate + PPI
33
What can be used for Bismuth-based Quadruple therapy if there is a salicylate allergy?
Bismuth subcitrate (Pylera)
34
When is Bismuth-based quadruple therapy 1st line?
Clarithromycin resistance rates > 15% and/ or patient has taken a macrolide antibiotic
35
What agents are used for concomitant therapy?
Clarithromycin + Amoxicillin + Metronidazole/ Tinidazole + PPI
36
What are 2nd line "salvage therapies"?
1. Levofloxacin-based Triple Therapy 2. Rifabutin-based Triple Therapy
37
What agents are used for Levofloxacin-based Triple Therapy?
Amoxicillin + Levofloxacin + PPI
38
What agents are used for Rifabutin-based Triple Therapy?
Omeprazole + Amoxicillin + Rifabutin
39
When would Rifabutin- based triple therapy be used?
persistent HP infection; preferred if patient received clarithromycin therapy prior
40
How long after eradication is a PPI continued for?
2 weeks
41
What is used to treat H. pylori negative ulcers?
H2 antagonists Sucralfate PPI
42
How long does it take for H2 antagonists and Sucralfate to heal ulcers?
6-8 weeks
43
How long does it take for PPIs to heal ulcers?
4 weeks
44
Which kind of ulcers are more difficult to treat?
gastric ulcers
45
What are treatment options for NSAID induced ulcers?
1. D/c NSAID 2. Stardard healing dose of H2RA, sucralfate, or PPI
46
What are treatment options for NSAID induced ulcers when NSAIDs cannot be discontinued?
1. Decrease dose 2. APAP, non-aceylated agent, selective COX-2 inhibitor 3. Use PPI
47
What patients should receive long term maintenance therapy with a PPI or H2RA?
1. HP positive ulcers with failed eradication attempts 2. refractory ulcers 3. heavy smokers
48
What agents are best for chronic NSAID users to prevent recurrence of ulcers?
1. PPIs 2. Misoprostol
49
What are important counseling points for patients with PUD?
1. communicate cause 2. address risk factors 3. rationale of multi-drug regimens and importance of adherence + completion of therapy 4. make patient aware of GI bleeding
50
What are signs of GI bleeding?
1. tarry stools 2. abdominal pain 3. vomiting with blood

GI (23 decks)

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