Term
| most common causes of PUD |
|
Definition
1. H. pylori
2. NSAIDs
3. stress-related mucosal damage |
|
|
Term
|
Definition
smoking
EtOH
corticosteroids (w/NSAIDs) |
|
|
Term
abdominal pain that is usually relieved with eating
but pain comes back 1-3hrs after eating |
|
Definition
|
|
Term
| ulcer pain that is precipitated or worsened by eating food |
|
Definition
|
|
Term
| non-pharmacologic tx for PUD |
|
Definition
eliminate or reduce:
psychological stress
cigarette smoking
use of nonselective NSAIDs
foods/drinks that cause dyspepsia or exacerbate ulcer sxs |
|
|
Term
| endoscopic and non-endoscopic tests for dx H. pylori |
|
Definition
endoscopic: histology, culture, biopsy (rapid) urease
non-endoscopic: Ab detection (lab or office), urea breath test, stool antigen |
|
|
Term
| why is it important to know whether pt w/ suspected PUD have taken abx or bismuth w/in the previous 4 weeks or PPI w/in the previous 2 weeks? |
|
Definition
-abx or bismuth w/in previous 4wks
-PPI w/in previous 2wks
may produce false negative results in testing for H. pylori
(EXCEPT AB DETECTION TESTS!) |
|
|
Term
| tx regimen for H. pylori ulcer |
|
Definition
| at least 2 abx and an anti-secretory drug (PPI or H2RA) |
|
|
Term
| how is the tx regimen different for active H. pylori PUD |
|
Definition
continue PPI additional 2wks
or continue H2RA additional 2-4wks |
|
|
Term
| what is the sequential H. pylori tx regimen |
|
Definition
PPI + Amox (1g bid X 5days)
then PPI + Clarithromycin (500mg qday X 5days) + tinidazole (500mg bid X 5days)
90% erradication rate |
|
|
Term
| two methods of NSAID induced PUDs |
|
Definition
1. NSAIDs directly or topically irritate gastric epithelium
2. NSAIDs inhibit endogenous GI mucosal prostaglandin synthesis (which protect the gastric lining) |
|
|
Term
| established risks factors for NSAID induced PUD |
|
Definition
-age >60
-prior PUD or UGI bleed
-high dose/more toxic NSAIDs
-concomitant use of corticosteroid, anticoagulant, antiplatelet (ASA, clopidogrel), oral bisposphonates, or SSRIs
-chronic illness (CV disease) |
|
|
Term
| possible risk factors for NSAID induced PUD |
|
Definition
NSAID-related dyspepsia
H. pylori infection
Rheumatoid arthritis
EtOH use
questionable: smoking |
|
|
Term
| which salicylates and non-salicylates are assoc w/ a decreased incidence of GI toxicity |
|
Definition
- selective COX-2 inhibitor (CELECOXIB)...lowest
- partially selective NSAIDs (etodolac, nabumetone, meloxicam)
- non-acetylated salicylates (salsalate, trisalicylate)
|
|
|
Term
what is COX-1 responsible for
COX-2?
what type of NSAID inhibits both COX-1 and COX-2 |
|
Definition
COX-1: for platelet formation (if inhibited, platelets DO NOT help stop bleeding)
COX-2: inflammation (so a COX-2 inhibitor inhibits inflammation)
traditional NSAIDS are nonselective and therefore inhibit both COX enzymes |
|
|
Term
| what is the only selective COX-2 inhibitor NSAID |
|
Definition
|
|
Term
| what is misoprostol cotherapy used for |
|
Definition
it is a prophylaxtic tx for prevention of NSAID induced ulcers in high risk pts
the target dose is 20mcg tid
*but must start with low dose and titrate up to reduce diarrhea and GI distress (abdominal cramping) |
|
|
Term
which is more effective:
PPIs and non-selective NSAID
OR
COX-2 inhibitor medication |
|
Definition
| equally effective in high risk pts |
|
|
Term
| H2RA blockers are effective at preventing which kind of ulcer |
|
Definition
|
|
Term
| sucralfate and antacids are effective at preventing which kind of ulcer |
|
Definition
|
|
Term
| approved tx for ulcer disease |
|
Definition
H2RA, PPI, or sucralfate
unless the NSAID must be continued- then PPI is treatment of choice |
|
|
Term
| when treating an NSAID induced ulcer and the pt must stay on an NSAID, what considerations should you make |
|
Definition
-reduce the NSAID dose
-switch to a non-acetylated salicylate (salsalate), partially selective COX-2 inhibitor, or a COX-2 inhibitor (celocoxib)
-and PPIs become the treatment of choice (over H2RAs or sucralfate) |
|
|
Term
peptic ulcer usually mucosal ischemia d/t decreased gastric blood flow
occurs in critically ill pt w/ physiologic stress (multiple trauma, multi-system organ failure, etc)
hypersecretion of gastric acid usually not present |
|
Definition
stress-related mucosal damage (SRMD)
prevention options: H2RA (most common for SRMD), antacids, sucralfate, PPI |
|
|
Term
| syndrome cxc by hypersecretion of gastric acid, calls for large initial dosing of PPI |
|
Definition
Zollinger-Ellison Syndrome
Ome-, Lanso-, Rebprazole: 60mg/day, then inc based on response and to reduce acid secretion <10mEq/hr
second-line tx: Octreotide (directly inhibits gastric acid secretion and gastrin release) |
|
|
Term
| when should PUD pt begin to feel relief from PPI or H2RA |
|
Definition
|
|
Term
| general duration of PPI, H2RA, or sucralfate pharmacotherapy for duodenal or gastric ulcer healing |
|
Definition
PPI: 4wks
H2RA: 6-8wks
sucralfate: 6-8wks |
|
|
Term
| indications for maintenance pharmacotherapy of PUD |
|
Definition
-frequent ulcer recurrences
-hx of ulcer-related bleeding
-healed refractory ulcer
-failed H. pylori eradication
-heavy smokers
-cont. NSAID tx |
|
|
Term
| factors that decrease lower esophageal sphincter (LES) tone |
|
Definition
-foods: high fat, chocolate, peppermint, spearmint
-smoking
-medications
-hormones
-pregnancy, chalasia, scleroderma
-direct irritants: spicy foods, orange and tomato juice, caffeine |
|
|
Term
| drugs that decrease the lower esophageal sphincter |
|
Definition
-calcium channel blockers (DHP)
-estrogens
-theophylline
-progesterone
-nitrates, tetracycline, anticholinergics, barbituates, dopamine, ethanol |
|
|
Term
| dietary changes in lifestyle modification treatment of GERD |
|
Definition
-avoid foods that decrease LES tone: fats, chocolate, EtOH, mints
-avoid foods w/ direct irritant effect: spicy, tomato and orange juice, coffee
-eat small meals
-avoid eating 2-3hrs before bed
-remain upright 1-2hrs after eating
-eat protein rich meals (helps LES tone)
-weight reduction |
|
|
Term
| lifestyle modifications for pts with GERD |
|
Definition
-raise the head of the bed
-dietary changes
-avoid EtOH
-avoid tight-fitting clothes
-stop smoking
-discont. meds that promote reflux: CCB, BB, theophylline, nitrates
-take meds that irritate the esophagus w/ lots of liquid |
|
|
Term
phase 1 GERD
describe and what is recommended tx |
|
Definition
intermittent, mild heartburn
lifestyle modifications and pt. directed therapy
-antacids
-OTC H2RA or OTC PPI |
|
|
Term
phase IIA GERD
describe and what is recommended tx |
|
Definition
symptomatic relief of GERD
-lifestyle modifications
-Rx strength H2RA (6-12wks) or PPI (4-8wks) |
|
|
Term
phase IIB GERD
describe and what is recommended tx
|
|
Definition
erosive esophagitis or moderate-severe sxs or complications
-lifestyle modifications
-PPI (bid 4-16wks) or H2RA (qid 4-12wks) |
|
|
Term
phase III GERD
describe and what is recommended tx |
|
Definition
interventional therapies:
anti-reflux sx
endoscopic therapies |
|
|
Term
|
Definition
chest pain
hoarseness
chronic cough |
|
|
Term
|
Definition
non-allergic asthma
dental erosions
pharyngitis |
|
|
Term
|
Definition
continual pain
dysphagia/odynophagia
bleeding
unexplained weight loss >5%
choking (acid causing coughing, SOB or hoarseness) |
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