PUD Case

Question 1

major independent lifestyle rf for symptomatic and asymptomatic PUD

Answer 1

smoking

Question 2

more than __ cigarettes/day increases risk of perforated peptic ulcer threefold

Answer 2

15

Question 3

__ in high concentrations damages the gastric mucosal barrier

Answer 3

etoh

Question 4

epigastric pain w. PUD is worse after

Answer 4

eating

Question 5

BUN:Cr ratio in PUD is often

Answer 5

>30:1

Question 6

why is BUN:Cr ratio elevated in PUD

Answer 6

blood is absorbed as it passes through small bowel → decreased renal perfusion

Question 7

what do higher BUN:Cr ratios indicate

Answer 7

higher likelihood of bleeding from UGI source

Question 8

common EGD findings of PUD

Answer 8

oozing gastric hemorrhage

nonbleeding visible vessel

Question 9

ddx for UGIB

Answer 9

PUD

esophagitis

angiodysplasia

portal HTN

mallory-weiss syndrome

UGI tumor

Question 10

4 rf for PUD

Answer 10

h.pylori

nsaids

physiologic stress

excess gastric acid

Question 11

etiology of NSAID induced PUD

Answer 11

prostaglandin/COX-1 inhibition → mucosal damage

Question 12

abnormal dilated tortuous vessel in UGI

Answer 12

angiodysplasia

Question 13

3 rf for angiodysplasia

Answer 13

renal dz

aortic stenosis

hereditary

Question 14

peptic ulcers are defects in __ mucosa (2)

that extend thru the __

and persist dt __

Answer 14

gastric or duodenal

muscularis mucosa

acidic gastric acid

Question 15

NSAIDs are associated w. __ ulcers

and increased risk of __

Answer 15

refractory

complications

Question 16

all pt’s w. PUD should undergo __ testing

Answer 16

H.pylori

Question 17

when can h.pylori testing be done

Answer 17

bx during EGD

Question 18

t/f: if actively bleeding, a negative bx rules out H.pylori

Answer 18

F!

Question 19

if h.pylori test is negative in active bleeding pt, what 2 tests can be used to confirm negative dx

Answer 19

urea breath

stool antigen

Question 20

ASAP tx for PUD (4)

Answer 20

2 large bore IVs - at least 16 g

NPO

bolus of 500-1000 cc of fluids

GI consult for EGD

Question 21

transfusion threshold

Answer 21

Hgb 7

Question 22

transfusion threshold for high risk PUD pt

Answer 22

< 8

Question 23

indication for high risk PUD pt

Answer 23

CAD

Question 24

other tx considerations for PUD

Answer 24

IV esomeprazole OR pantoprazole

stop NSAIDs

Question 25

dosing for esomeprazole or pantoprazole if pt is actively bleeding

Answer 25

80 mg

Question 26

if pt needs to stay on ASA, what reduces risk of ulcer complications/recurrence

Answer 26

maintenance PPI therapy → omeprazole 20 mg

Question 27

continued tx for all PUD pt's should include __ to facilitate healing

Answer 27

PPI → omeprazole 20-40 mg qd

Question 28

indications for complicated PUD (4)

Answer 28

bleeding perforation penetration gastric outlet obstruction

Question 29

complicated PUD pt's should get __ to facilitate healing

Answer 29

IV PPI

Question 30

t/f: PPIs cause stronger acid suppression than H2 blockers and control sx faster and have higher healing rates

Answer 30

T!

Question 31

\_\_ pH levels stabilize clots and heal NSAID related ulcers more effectively than H2 blockers

Answer 31

higher

Question 32

T/F: combining PPIs and H2 blockers is beneficial to PUD pt's

Answer 32

F!

Question 33

when can a pt w. an actively bleeding ulcer be switched from IV to PO PPI

Answer 33

72 hours after endoscopy

Question 34

dose and duration for PO PPI for pt who has been switched from IV to PO

Answer 34

omeprazole 20 mg x 4-12 weeks

Question 35

\_\_ can heal duodenal ulcers but are not recommended for peptic ulcers (2)

Answer 35

antacids sucralfate

Question 36

2 lifestyle recommendations for PUD

Answer 36

stop smoking limit etoh to 1 drink/day

Question 37

2 tools to calculate PUD risk and outpt management

Answer 37

glasgow blatchford score (GBS) rockfall score

Question 38

when is GBS calculated

Answer 38

at patient presentation *doesn't need EGD*

Question 39

when is rockfall calculated

Answer 39

after endoscopy

Question 40

what factors does GBS use (8)

Answer 40

BUN Hgb SBP pulse presence of melena syncope hepatic dz cardiac failure

Question 41

what factors does rockfall use (5)

Answer 41

age presence of shock comorbidity dx endoscopy results

Question 42

indications for d.c post endoscopy (3)

Answer 42

no comorbidities stable vitals normal Hgb

Question 43

2 indications for somatostatin/octreotide

Answer 43

endoscopy not available help stabilize pt before definitive therapy can be done

Question 44

how do somatostatins/octreotide work

Answer 44

reduce splanchnic blood flow inhibit gastric acid secretion +/- protective effect on gastric cells

Question 45

what 2 therapies are much more effective for PUD than somatostatin/octreotide

Answer 45

PPI endoscopy

Question 46

\_\_ can predict recurrent peptic ulcer hemorrhage

Answer 46

EGD findings

Question 47

classification that is used to objectify EGD findings for PUD

Answer 47

Forrest

Question 48

in forrest classification, what counts as a stigmata of recent hemorrhage

Answer 48

anything other than a clean ulcer base

Question 49

what are the forrest classifications (6)

Answer 49

spurting hemorrhage oozing hemorrhage nonbleeding visible vessel adherent clot flat pigmented spot clean ulcer base

Question 50

3 EGD tx for PUD

Answer 50

thermal coagulation therapy hemostatic clips +/- injection therapy

Question 51

what is EGD injection therapy

Answer 51

epinephrine

Question 52

who determines risk for rebleeding in PUD pt

Answer 52

GI

Question 53

generally, when can you restart anticoagulation/antiplatelet therapy (ASA) after PUD tx

Answer 53

1 day following endoscopic hemostasis

Question 54

t/f: data shows that restarting ASA for secondary prevention reduces mortality risk in pt's w. CV or cerebrovascular dz w. bleeding from PUD

Answer 54

T!