655 - Exam I - Pud

Front 1

What percentage of the US population is infected w/ H. pylori?

Back 1

~30%

Front 2

What are the two main causes of PUD?

Back 2

H. pylori and NSAIDs

Front 3

What is the percentage of elderly patients in the US who take NSAIDs?

Back 3

~40%

Front 4

Duodenal vs. Gastric Ulcers: Diffuse Gastric Pain?

Back 4

Both

Front 5

Duodenal vs. Gastric Ulcers: May be painless (w/ NSAID use)?

Back 5

Both

Front 6

Duodenal vs. Gastric Ulcers: Dyspepsia?

Back 6

Both

Front 7

Duodenal vs. Gastric Ulcers: May lead to significant bleeding, hemorrhage, or obstruction?

Back 7

Both

Front 8

Duodenal vs. Gastric Ulcers: Most present before age 40?

Back 8

Duodenal Ulcers

Front 9

Duodenal vs. Gastric Ulcers: Some NSAID association (as opposed to strong NSAID association)?

Back 9

Duodenal Ulcers

Front 10

Duodenal vs. Gastric Ulcers: Pain on empty stomach?

Back 10

Duodenal Ulcers

Front 11

Duodenal vs. Gastric Ulcers: Food alleviates pain?

Back 11

Duodenal Ulcers

Front 12

Duodenal vs Gastric Ulcers: Usually seen after age 40?

Back 12

Gastric Ulcers

Front 13

Duodenal vs. Gastric Ulcers: Strong association w/ NSAID use (as opposed to some association)?

Back 13

Gastric Ulcers

Front 14

Duodenal vs. Gastric Ulcers: Pain after eating?

Back 14

Gastric Ulcers

Front 15

What are the 5 "alarm symptoms" for PUD? What should be done about them?

Back 15

Alarm Symptoms: Bleeding, Weight Loss, Dysphagia (difficulty swallowing), Odynophagia (pain when swallowing), Emesis (vomiting). Anyone experiencing these needs to be referred to a gastroentronologist for evaluation.

Front 16

What is melena?

Back 16

Melena is black tarry stool associated with gastrointestinal hemorrhage.

Front 17

What is the medical term for vomit containing blood?

Back 17

Hematemesis

Front 18

What is the most common complication associated with PUD and what percentage of PUD patients experience it?

Back 18

GI bleeding, which is experienced by ~15% of PUD patients.

Front 19

What is the second most common complication associated with PUD and what percentage of PUD patients experience it?

Back 19

Gastric perforation, which is experienced by 6 to 7% of PUD patients.

Front 20

What is the third complication associated with PUD and what percentage of PUD patients experience it?

Back 20

Gastric outlet obstruction, which is experienced by about 1% of patients.

Front 21

4 Defensive Factors w/ respect to PUD.

Back 21

Prostaglandins, Bicarbonate, Mucus, Growth Factors

Front 22

7 Aggressive Factors w/ respect to PUD.

Back 22

Acid, Pepsin, Smoking, Helicobacter Infection, NSAID Use, Environmental Factors, Genetic Factors

Front 23

What are the two methods of diagnosing PUD?

Back 23

1) Barium Radiographic Study (considered the "gold standard") and 2) Endoscopic Procedure

Front 24

How does H. pylori protect itself from the stomach's acidic environment?

Back 24

It has sheath flagella that allow it to burrow down into the gastric mucosa. It also produced a urease, which catalyzes the conversion of urea to CO2 and ammonia. The ammonia neutralizes the acid immediately surrounding the bacteria.

Front 25

What type of bacteria is H. pylori?

Back 25

H. pylori is a gram negative rod.

Front 26

If someone has a duodenal ulcer, what are the odds they are infected with H. pylori?

Back 26

95%

Front 27

If someone has a gastric ulcer, what are the odds they are infected with H. pylori?

Back 27

80%

Front 28

What three complications are associated specifically w/ H. pylori?

Back 28

1) Gastric mucosa-associated lymphoid tissue (MALT) lymphoma, 2) Gastric adenocarcinoma, 3) Gastritis

Front 29

Who should be tested for H. pylori?

Back 29

All patients presenting w/ 1) active PUD, 2) Hx of confirmed PUD, 3) MALT lymphoma, & 4) 4 to 6 wks POST treatment should be tested for H. pylori. Additionally, all patients w/ uninvestigated frequent dyspepsia who are less than 55 yo and have no alarm symptoms should be tested (those who have alarm symptoms are referred anyway).

Front 30

List four factors that can decrease the sensitivity of tests identifying active H. pylori infections.

Back 30

PPIs, bismuth (Pepto-Bismol), or antibiotics. [Note: The sensitivity of the fecal antigen test is also decreased by bleeding.]

Front 31

What two methods are used to test for H. pylori eradication?

Back 31

1) Urea Breath Test & 2) Fecal Antigen Test

Front 32

List 7 risk factors for NSAID-associated bleeding.

Back 32

1) Age > 60 yo, 2) anticoagulant use, 3) corticosteroid use, 4) H. pylori infection, 5) high NSAID dose or use of two or more NSAIDs, 6) PUD Hx or Hx of complications, 7) Hx of cardiac disease (aspirin < 325 mg/d)

Front 33

What is the spontaneous remission rate of gastric MALT lymphoma following eradication of H. pylori?

Back 33

80%!

Front 34

Describe two first line treatments for H. pylori eradication that are no longer recommended due to the rise of antibiotic resistances.

Back 34

PPI bid (esomeprazole q day instead) + clarithromycin 500 mg bid + amoxicillin 1 g bid OR PPI bid + clarithromycin 500 mg bid + metronidazole 500 mg bid [Duration = 14 days in either case] [Eradication Rate 70 to 85%]

Front 35

Describe the first line treatment for H. pylori eradication known as "quadruple therapy."

Back 35

Bismuth subsalicylate 525 mg 4x/d + metronidazole 250 mg 4x/d + tetracycline 500 mg 4x/d + EITHER ranitidine 150 mg bid OR PPI q day to bid [Duration = 14 days] [Eradication Rate 75 to 90%]

Front 36

Describe the first line treatment for H. pylori eradication known as "sequential therapy."

Back 36

PPI + amoxicillin 1 g bid for 5 days followed by PPI + clarithromycin 500 mg + EITHER tinidazole OR metronidazole 500 mg bid for 5 days [Eradication Rate > 90%]

Front 37

Describe the most recently developed first line treatment for H. pylori eradication.

Back 37

PPI + amoxicillin 1 g + clarithromycin 500 mg + (tinidazole or metronidazole) 500 mg bid [Duration = 14 days] [Eradication Rate Unknown]

Front 38

Lansoprazole dosing for Treatment of H. pylori

Back 38

30 mg po bid

Front 39

Omeprazole dosing for Treatment of H. pylori.

Back 39

20 mg po bid

Front 40

Pantoprazole dosing for Treatment of H. pylori.

Back 40

40 mg po bid

Front 41

Rabeprazole dosing for Treatment of H. pylori.

Back 41

20 mg po bid

Front 42

Esomeprazole dosing for Treatment of H. pylori.

Back 42

40 mg po daily

Front 43

Describe H. pylori Relapse Salvage Therapy

Back 43

Either 1) Bismuth Quadruple Therapy OR 2) PPI + amox 1 g bid + EITHER levofloxacin 500 mg daily OR moxifloxacin 400 mg daily

Front 44

How are PPIs different from H2RAs w/ respect to recommendation for the treatment of gastric vs. duodenal ulcers?

Back 44

PPIs can be used to treat both gastric and duodenal ulcers, while H2RAs are only recommended to treat duodenal ulcers.

Front 45

How does the duration of therapy differ for the treatment of gastric vs. duodenal ulcers?

Back 45

Gastric ulcers are treated for 8 wks (PPIs superior to H2RAs), while duodenal ulcers are treated for 4 wks (w/ either PPIs or H2RAs).

Front 46

How does the dosing of PPIs differ for the treatment of NSAID-induced ulcers versus H. pylori-induced ulcers?

Back 46

PPIs are dosed once a day for NSAID-induced ulcers, as opposed to twice a day for those induced by H. pylori. [The once daily dose of esomeprazole for H. pylori induced ulcers is cut in half, from 40 mg to 20 mg, for NSAID-induced ulcer treatment.]

Front 47

Describe three H2RA regimens for treatment of duodenal ulcers.

Back 47

1) Cimetidine 400 mg bid, 2) Ranitidine/Nizatidine 300 mg q day, 3) Famotidine 40 mg q day [All administered b/w evening meal and bedtime.]

Front 48

According to Professor Barnette, generally speaking, which two NSAIDs are less toxic w/ respect to the GI?

Back 48

Naproxen and Ibuprofen