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49 Cards in this Set

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  • Back
Dyspepsia = recurrent persistent pain or discomfort around midline of _____ abdomen for > than ___ weeks.
Causes of dyspepsia= 3., 4., 5. and others
1. upper
2. 2 weeks

3. NUD- ulcer undetectable by endoscapy
4. PUD- ulcer px
Endoscopy is necessary in pts w/ dyspepsia if the pt is >__, and if pt pxs w/ GI bleeding, anemia, unexplained wt loss, recurrent vomiting, dysphagia, abdominal mass, and/or jaundice
- 45
NUD- recurrent, and is there evidence usually of organic dz? Is H. pylori pathophys in this dz?
There is ___ clear tx for this dz.
- no evidence of organic dz
- H. pylori may be px but usually has not has a role in the dz
- no clear tx for NUD
PUD is caused by imbalance of defensive and aggressive factors, what are some defensive factors(3)?
What are some aggressive factors?
1. Prostaglanding
2. Mucus bicarb layer
3. blood q and cell renewal

4. H pylori
6. Smoking
7. Acid, pepsin, bile salts
90% chance of recurrence of PUD if ___ is not eradicated.

What are some lifestyle modifications helpful w/ PUD?
1. H. pylori

3. Elim ulcerogenic meds-- NSAIDs, corticosteroids
4. Minimize EtOH intake
Antacids- MOA
- reduces acidity by neutralizing secreted gastric acid, reacts w/ stomach acid to form salt and water
- inhibits proteolytic activity of pepsin if pH is > 4
- increases LES tone
Sodium bicarb- Class, Caution/CI
Class: Antacids
Caution: not recommended for long term use b/c it can produce SYSTEMIC alkalosis
CI: increases Na load-- CHF, Htn, and renal pts
Calcium Carb- Class, Caution
Class: antacids
Caution: may produce hypercalcemia, w/ v. high chronic dosing or w/ use of THIAZIDE diuretics
AlSalts- AE
1. Mg Salts-- diarrhea
2. Al Salts-- constipation
- combo may be effective
Antacids- DI
DI: quinolones, tetracylines, bisphosphonates- may result in failure of abx tx
- increase in gastic pH-- may interfere w/ absorption of itraconazole, ketoconazole, digoxin, phenytoin, and isoniazid
Antacids- Use, When to give?
Use: prn for breakthrough sx-- rapid onset but SHORT duration of action requiring frq dosing
- Give 1 HOUR after meal for maximal efficacy
H2RA belong to what larger class?
- antisecretory meds
- competitive inhibition of histamine at H2 receotors of the gastric parietal cells, inhibiting both BASAL and food stimulated acid secretion
- inhibition of cAMP dep pathway-- decreased proton pump activity
Cimetidine, famotidine, nizatidine, and ranitide- Class
H2RA- Use (types of tx)
- acute tx to heal ulcers--4-6 wks for DU, 8-12 wk for GU
- maintenance tx- for pts in whom h pylori has not been eradicated, if H pylori not eradicated then NO NEED for maintenance tx
- combo w/ bismuth citrate and 2 abx to eliminate H pylori
- rare- hepatitis, hemat tox, and dystonia esp in elderly w. reduced renal clearance
- CIMETIDINE- can cross BBB

DI: can decrease absorption of drugs that require acidic environment-- i.e. ketoconazol,e fluconazole, itraconazole, and protease inhibitors
Cimetidine- AE, Class
Class: H2RA
AE: Cimetidine has higher incidence of SE b/c it can cross the BBB- can cause nightmares, hallucination
- Long term use ass. w/ anti androgenic SE- gynecomastia, impotence, and decreased sperm count
Cimetidine- DI
DI: inhibits cytochrome P450 enzymes-- decrease metabolism & increases serum concentration of THEOPHYLLIN, phenytoin, warfarin, PROPRANOLOL, and diazepam
- also in GEN for H2RA-- reduced absorption of ketoconazole, fluconazole, itraconazol,e and protease inhibitors b/c of increase in gastric pH.
- binds to proton pump (H=/K+ ATP pump) of parietal cell irreversibly inhibiting secretion of H+ ions into gastric lumen
- MOST POTENT class of meds
Omeprazole, esomeprazole, lansoprazole, raberprazole- Class
- lansoprazole adn omeprazole= OTC and 1/5 of prescription costs
- prazole- Class, Use, AE
Class: PPI
Use: more rapid relief of pain adn healing rates
AE: some increased risk of aspiration pneumonia in mechanically ventilated pts, also some increased risk of hip fractures so council to get enough calcium
Omeprazole- DI
- Gen DI for all PPIs-- decreased bioavailability of drugs that depend on GI acidity for absorption- ketoconazole, itraconazole, and protease inhibitors
Omeprazole- inhibits cytochrome P450- increases levels of warfarin, phenytoin, digoxin, and diazepams
- slightly faster healing than w/ H2RA
- can use as part of multi drug regimen for H pylori eradication
- use PPI only at lowest effective dose to min risk of aspiration pneumonia and c. diff colitis
- take 30-60 min before meals-- drug starts off inactivated and is activated in acidic env
- usually BID
Cytoprotective Agents- MOA, drug name
- Sucralfate and Bismuth (peptobismol)- drug
- complex salt of sucros sulfate and AlOH -- Al dissociates-- leaving highly polar anion which binds to positively charged proteins in normal & diseased mucosa
- forms viscous adhesive protective barrier on ulcer crater- protects gastric lining against peptic acid, pepsin, and bile salts
- may increase secretion of local prostaglandins
Sucralfate- AE/DI
AE: constipation
DI: binds to other drugs and impairs absorption of phenytoin, digoxin, theophyliin, warfarin, quinolones, and tetracyclines
Sucralfate- Use
- requires multiple daily doses and is not as effective as PPI or H2RA for pain
- doubles the cost of tx
- ADVANTAGES--good for preggers b/c no systemic absorption
- NO increased risk of aspiration pneumonoia- good for pts on mech ventilators
Bismuth subsalicylate- Use, Class, Caution, Pt education
- H. pylori eradication-- multidrug regiment-- mild antimicrobial
Class: cytoprotective agents
Caution: in children b/c Reyes syn
Pt education- may turn stool grayish black- benign
H pylori increases the incidence of ___ and ___
1. MALT ass. lymphoma
2. adenocarcinoma
Methods to detect H pylori?
Caution of detection?
1. endoscopy- urease activity of h pylori is tested
2. serology- looks for IgG against h pylori
3. Urea breath test
4. stool antigen test

- FALSE NEGATIVES may occur in pts taking antisecretory agent or abx except for w/ serology tests
What is the usual tx for H. pylori?
- one anti secretory (PPI OR H2RA) and two abx- amoxacillin, clarithromycin, metronidazole, and tetracycline, and levofloxacin= ABs effective against H. pylori- cant really substitute other abx b/c these are the ones that are stable in acid environment
Is one abx treatment regimen appropriate for H. pylori?
If first course of tx doesn't work fo rH pylor then what can be used?
- No b/c low cure rate
- use DIFFERENT abx b/c pt might be resistant to the failed abx-- abx that work-- amox, clarithromycin, metronidazole, tetracycline- CMTA
Quadruple therapy for H. pylori?
Bismuth subsalicylate, metronidazole, tetracycline, and A PPI for 14 days has highest rate of efficacy (> 90%)
- good for pts allergic to penicillin
What is the idal tx for preggers?
- Sucralfate
NSAIDs are the other major cause of GI ulcers, about __ % of pts w/ prolonged NSAIDs use have ulcers.
NSAIDs weaken gastroprotective factors by inhibition of ___?
- 20%
- COX1
Should COX 2 inhibitors be used instead of COX 1 to protect stomach?
- no, not really b/c INCREASED CV risk and COX 2 selective shoul dbe avoided if pt has CAD
- celecoxib CI in pts w/ sulfonamide allergies
- use of Celecoxib w/ ASA- negates any GI protective advantage
Test for H. pylor before placing pts on long term ___ therapy. If pt is positive for H pylori then first treat H. pylori ____ beginning regimen.
- before
WHat is DOC when 1. NSAID must be continued in presence of ulcer dz, 2. if ulcer is large, or 3. there is sig upper GI bleeding?
- Omeprazole (PPI) at high dose
What is an effective prophylactic therapy for NSAID induced GU & PU?
What drugs are INEffective as prophylactic tx for NSAID induced ulcers?
- MIsoprostol (PGE1 analog)

- H2RA and sucrlafate- NOT effective
Misoprostol- CI, MOA
MOA: stable PGE1 analog that replenishes prostaglandin-- increases bicarb, mucus and mucosal blood flow
CI: women of child bearing age that may want to get pregnant-- is abortive agent
Stress induced ulcers are different from PUD b/c they are not ____
- these occur in untreated critically ill pts w/ in 24 to 48 hrs
1. recurrent
What is the tx for stress ulcers?
1. Treat underlying condition
2. Give antisecretory agents (h2RA, PPI)and agents that increase protective factors (sucrlfate (particularily good) , antacid)
GERD- when is endoscopy necessary?
- pts greater than 45 w/ alarming sx- dysphagia, bleeding, unexplained wt loss, choking, chest pain
- present for >5 yrs
- lower threshold for males b/c much mroe likely fro Barretts esophagus
Controversy w/ H pylori and GERD?
- may be protective
Besides antiescretory agents(PPI, H2RA) and acid neutralizing agents (antacids), what class of meds can be given to GERD pts?
- Promotility agents such as metoclopromide, bethanecol, and cisapride
Which method should be followed w/ GERD pts- step down or step up?
- both depending on severity of sx
Which of the antisecretory agents is better for GERD?
- PPI over H2RA
Promotility agents in GERD- MOA, drug names
- Drugs- metaclopramide, bethanechol, & cisapride
- Metoclopramide--Antagonizes central and peripheral dopamine receptors
- Bethanechol- Sensitizes receptors in GI tract to acetylcholine
- increases LES tone and improves gastric motility
Metoclopramide in GERD-AE
- extrapyramidal sx w/ high dose
- avoid in pts w/ PD-antagonizes effects of dopaminergic agents
Betahnecol- MOA, CI
MOA: stimulates cholinergic receptors, ↑ GI motility & ↑ LES tone to relieve SYMPTOMS of reflux
CI: PUD, asthma
SE: cholinergic SE
When is H2RA goood for pts w/ GERD?
- for nighttime sx