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84 Cards in this Set
- Front
- Back
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what are the common forms of Peptic ulcer disease
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H Pylori
NSAID Stress ulcers |
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what are some less common causes of PUD
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cig smoking
psychological stress Zollinger Ellison syndrome |
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what type of ulcers are chronic and cause frequent ulcer recurrence
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h pylori
nsaid |
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what are some factors for recurrence
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h pylori
nsaid cig smoking alcohol gastric acid hypersecretion |
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what are the aggressive factors of PUD
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gastric acid (independent activity)
pepsin (proteolytic activity) |
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what pH is pepsin
-activation -inactivated -irreversibly |
activation: 1.8-3.5
inactivated: 4 irreversibly destroyed: 7 |
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what are the protective factors
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mucus and bicarbonate secretion
endogenous prostaglandins (prevent deep mucosal injury) |
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what are the most common ways H pylori can be transmitted
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person to person
gastro-oral fecal-oral |
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what is the pathophysiologiy of H Pylori
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adherence to pedestals
alters host inflammatory response produces urease, lipases, proteases produces acid inhibitory proteins |
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what does the production of urease and acid inhibitory proteins do for H pylori
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urease converts urea to ammonia and CO2
-the ammonia can be used as a buffer to protect it from the acid production of acid inhibitory proteins allows H pylori to adapt to low pH (protects it from low pH) |
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why are enterically coated NSAIDs still able to cause ulcers
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cause systemic prostaglandin inhibiton
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what does COX 1 do
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produces protective prostaglandins
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what does COX 2 do
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produces prostaglandins that cause inflammation, fever, and pain
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what induces COX 2
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inflammatory stimuli
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is NSAID related ulcers dose dependent?
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yes, but may occur with low doses
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what are some factors of NSAID use that can increase risk of ulcers and complications
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potency
longer duration COX 1 inhibitor vs COX 2 using multiple NSAIDS concomitant use of certain drugs |
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what are complications of PUD
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bleeding
perforation penetration gastric outlet obstruction |
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how does GI bleeding occur
how may it present and what is the most important risk factor |
occurs: ulcer moves into artery
present: melana (black stool), hematemesis (vomitting blood) most important risk factor: NSAID use |
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how does perforation occur
what are the majority of them caused by how does it present |
occurs: ulcer opens up in the perotineal cavity
majority caused by NSAIDs presents: sharp pain that starts in the gastric area but spreads to abdominal area |
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what is Penetration
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ulcer moves into a nearby organ
-ex: pancrease, biliary tract, liver |
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what is Gastric outlet obstruction due to
what are the symptoms |
due to: scarring, edema of duodenal bulb, muscular spasm
symptoms: ANOREXIA, WEIGHT LOSS, EARLY SATIETY, BLOATING, n/v |
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what complications are most often seen with chronic PUD
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perforartion
penetration gastric outlet obstruction |
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can you diffrentiate between an ulcer due to H. Pylori vs NSAID
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no
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what symptoms are more common in pts with gastric ulcer than duodenal ulcer
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nausea
vomitting anorexia |
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what are alarm symptoms that are signs of ulcer related complications
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anemia
weight loss loss of appetite (early satiety) vomitting |
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symptoms in general may be described as
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burning
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what is the difference between duodenal ulcer pain and gastric ulcer pain
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duodenal ulcer pain: 1-3 hours after meals, RELIEVED WITH FOOD
gastric ulcer pain: FOOD MAY CAUSE OR ACCENTUATE PAIN |
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when is H pylori testing recommended
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when eradication is planned
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what are the testing options for H Pylori
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endoscopic
non endoscopic |
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when you are planning on doing endoscopic therapy what must you do first
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hold antibiotics and bismuth salts for 4 weeks
hold PPI for 1-2 weeks |
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how are ulcer like symptoms in pts 55 years and up investigated
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non endoscopic therapy
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what are the non endoscopic tests
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urea breath test
serologic test fecal antigen test |
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what test is done to confirm that H pylori has been eradicated
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Urea Breath Test
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what non endoscopic test may be useful in children
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fecal antigen test
-comparable to UBT in initial detection |
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why can't Serologic tests be used to see if eradication was successful
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antibodies remain even after successful eradication
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what does Serologic tests test for
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antibodies
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what non endoscopic test is good for initial diagnosis in untreated patients
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serologic test
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diagnosis of PUD depends on what? and what is used?
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diagnosis depends on visualizing the ulcer
upper endoscopy is used to visualize. |
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what are the treatment goals of PUD, H pylori and NSAID also
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relieve pain
heal ulcer prevent recurrence reduce complications goals for H pylori + pts: -eradicate H pylori -heal ulcer -cure the disease goals for NSAID induced ulcers: -heal ulcer as quickly as possible |
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what does treatment depend on
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cause: H pylori vs NSAID
initial or recurrent infection whether complications have occurred |
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what are the non pharmacological treatment for PUD
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reduce/stop psychological stress
reduce/stop cig smoking STOP USE OF NSAIDS ESPECIALLY ASA avoid food/drinks that cause dyspepsia - spicy food, caffeine, alcohol |
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what can you use if you have pain due to PUD
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acetaminophen or nonacetylated salicylate
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what is an example of a nonacetylated salicylate
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salsalate
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what are the choices of therapy for H pylori erradication (1st course of treatment)
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PPI triple therapy
Bismuth based quadruple therapy Sequential therapy |
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what is PPI triple therapy
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PPI + clarithromycin + amoxicillin or metronidazole for 10-14 days
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why would you prefer using amoxicillin over metronidazole in PPI triple therapy
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almost no bacterial resistance
few AE leaves Metronidazole to be used as 2nd line treatment |
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what is the 1st line therapy for H Pylori eradication
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PPI triple therapy
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what is the Bismuth quadruple therapy
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PPI or H2-RA + bismuth + tetracycline + metronidazole for 10-14 days
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if someone has a penicillin allergy what treatment can you use for H pyloric eradication
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Bismuth quadruple therapy
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what is 2nd line therapy for H pylori erradication
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bismuth quadruple therapy
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what is sequential therapy for H pylori eradication
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PPI and amoxicillin for 5 days
then PPI clarithromycin and metronidazole for 5 days |
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if treatment failure occurs after trying the 1st line regimen what can you do
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PPI 3 drug regimen with different ABx than before
bismuth quadruple regimen with PPI not H2RA |
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what are the antibiotics that are in the various regimens for H Pylori eradication and can they be substituted
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metronidazole
amoxicillin tetracyclin clarithromycin THESE CAN NOT BE SUBSTITUTED WITH DRUGS OF THE SAME CLASS |
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what is the treatment for NSAID induced ulcers
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test for H pylori
IF POSITIVE: do PPI triple therapy IF NEGATIVE: STOP NSAID, tx with either PPI, H2RA, or sucralfate |
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why is PPI prefered for NSAID induced ulcers that are negative for H pylori
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accelerate healing process
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if pt has NSAID induced ulcer and NSAID is necessary what is the course of treatment
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if H pylori positive initiate therapy with PPI triple regimen
if H pylori negative initiate therapy with PPI (PPI should be extended for 8-12 weeks) -reduce NSAID dose -Switch to APAP or Nonacetylated Salicylate (salsalate) -use more selective COX 2 inhibitor |
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what is the drug of choice in NSAID induced ulcers if the NSAID still needs to be continued
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PPI (PPI should be extended for 8-12 weeks)
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what can you use to reduce risk of NSAID ulcer and Ulcer related complications
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Misoprostol cotherapy
PPI cotherapy switch to selective COX 2 inhibitor |
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what is the dose of Misoprostol
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200 mcg by mouth 4x/day (switch to 3x/day if intolerable)
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what is the SE of Misoprostol
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diarrhea
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what is the fixed combo for misoprostol cotherapy
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misoprostol 200 mcg and diclofenac 50 mg or 75 mg max
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what kind of NSAID related ulcer are H2RA cotherapy ok for
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reduces NSAID related duodenal ulcer NOT GASTRIC ULCER
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what drug can you use to relieve NSAID related dyspepsia
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H2RA
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why is H2RA cotherapy not recommended as prophylactic cotherapy
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not as effective
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how do PPI work
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inhibit basal and stimulated gastric acid secretion
DOSE DEPENDENT |
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when are PPI most effective
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30 - 60 mins before meals
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with PPI the duration of suppression is a function of binding to _____ of parietal cell, longer than elimination half lives
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with PPI the duration of suppression is a function of binding to H/K ATPase of parietal cell, longer than elimination half lives
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name the generic
prilosec zegerid prevacid aciphex protonix nexium |
prilosec - omeprazole
zegerid - omeprazole sodium bicarbonate prevacid - lansoprazole aciphex - rabeprazole protonix - pantoprazole nexium - esomeprazole |
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what PPI is not labeled as an antiulcer agent
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dexlansoprazole
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is there renal dosing for PPI
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no renal dosing
consider dose adjustment in severe hepatic disease |
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what is the issue with immediate release formulations of PPI
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contain sodium bicarbonate therefore
contrindicated in metabolic alkalosis, hypokalemia, and must watch Na content in Na restricted diets |
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what are the Drug interactions with PPI
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increase gastric pH
inhibit CYP2C19 increase metabolic clearance and decrease GI absorption of levothyroxine reduce effectiveness of clipidogrel |
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what drugs are affected by PPI increasing gastric pH
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this may alter bioavailability of some drugs that depend on pH to work
example: ketoconazole, digoxin |
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what PPI inhibit CYP2C19 and what drugs are affected by this
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omeprazole and esomeprazole inhibit CYP2C19
this may decrease elimination of phenytoin, warfarin, diazepam, carbamazepine |
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what occurs due to PPI affect on levothyroxine
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increase TSH
increase dose of levothyroxine must be given |
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what PPI aren't given with clopidogrel and why
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esomeprazole, omeprazole, omeprazole/sodium bicarbonate
reduce its effectiveness PPI in general may attenuate antiplatelet effect |
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do you have to adjust the dose renally in H2 Rc antagonist
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yes
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name the generic
Tagamet Pepcid Axid Zantac |
Tagamet - cimetidine
Pepcid - famotidine Axid - nizatidine Zantac - ranitidine |
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what AE occurs in all H2 Rc Antagonist
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thrombocytopenia
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what H2 RcA inhibits CYP450 isoenzymes and what drugs are affected
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tagamet (cimetidine)
theophyline, lidocaine, phenytoin, warfarin, clopidogrel can be affected |
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how does Sucralfate work
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promotes healing by improving mucosal repair
-forms a viscous adhesive substance that coats stomach against peptic acid, pepsin, bile salts MAY ALSO SUPPRESS H PYLORI INFECTION |
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what antiulcer agent is contraindicated in women and why
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Misoprostol b/c produces uterine contractions
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what antiulcer agent CAN NOT BE USED FOR TREATMENT AND IS ONLY USED FOR PREVENTION
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misoprostol
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what are the bismuth agents
do they inhibit or neutralize acid |
pepto-bismol
do not inhibit or neutralize acid often contain salicylates so must watch to see what other salicylates pt is on |
