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Gastrointestinal (GI) tract comprises the
stomach and the intestines
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Peptic is an adjective that refers to any part of the body that ________. The peptic areas of the human body under normal circumstances are the ________
- normally has an acidic lumen, or is related to or promotes digestion
- stomach and duodenum
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Duodenum is the part of the _______ closest to the ________ where most ________ occurs. Large intestine is called the _______
- small intestine
- stomach
- absorption into the blood
- colon
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PUD is a general term describing a group of acid-peptic disorders of the ______, primarily the ____, _______, and ______. Defined as a
- upper GI tract
- esophagus, stomach, and duodenum
- circumscribed loss of tissue or break that occurs in the GI mucosa extending through the smooth muscle that lines the GI tract
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A gastric ulcer occurs _______ and a duodenal ulcer occurs _______ and a duodenal ulcer is _____ than gastric ulcer
- In the stomach
- In the duodenum
- more common
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Peptic Ulcer Disease Symptoms
- Epigastric pain
- Food or antacids usually relieve the pain
- Feeling of being hungry
- Heartburn, belching, and bloating
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In 1983 it was discovered that _____% of duodenal and ____% of gastric ulcers are caused by a bacteria called ________.
- 90%
- 80%
- Helicobacter pylori (H. pylori)
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Where does the Helicobacter pylori (H. pylori) come from and how does it affect the stomach and duodenum?
- Resides in the mucus overlying the gastric epithelium in infected individuals
- Damages the GI mucosa via enzymes that degrade gastric cells and alters the inflammatory response
- This allows acids to cause an ulcer in the mucosa in the stomach and duodenum
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Histamine stimulates production of _________. This is a _______ cause of ulcers.
- gastric juices in the stomach
- secondary
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_______ is the most common of the chronic conditions of the upper gastrointestinal tract and is the _______. The most common complaint is ________
- GERD (Gastroesophageal Reflux Disease)
- Reflux or “backing up” of gastric contents from the stomach into the esophagus
- heartburn, but the individual may also complain of epigastric pain (pain in and around the stomach area).
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What is Reflux esophagitis
- a form of GERD
- an inflammation of the esophagus whengastric contents stay in contact for prolonged periods of time with the mucosal tissue of the esophagus
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Other complications from GERD
- –Reflux into the oral cavity can cause tooth erosion. Occurs at night.
- -GERD can lead to dysphagia (difficulty swallowing)
- –Esophageal ulcers
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What are some risk factors for GERD
- Alcohol
- Smoking
- Spicy foods
- Medications
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Calcium channel blockers–Aspirin and NSAIDs - –Alendronate (Fosamax, for treatment of osteoporosis)
- –Tetracycline
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What are some conditions that can be caused by GERD
- Barrett's Esophagus: precancerous change in the cells lining the esophagus
- Esophageal cancer
- Esophageal perforation: hole in the esophagus
- Esophageal ulcers
- Esophagitis: inflammation of the esophagus
- Esophageal Stricture: narrowing of the esophagus
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What is the Pharmacotherapy for Treating Peptic Ulcers
- Proton pump inhibitors (PPI’s)– Quick pain relief and accelerated healing of the ulcer
- Antibiotics –Needed to eradicate the H. pylori infection – remember……no effect on GERD, this is for peptic ulcers
- Antihistamines (Histamine2-receptor antagonists; H2RAs) –For symptomatic relief of pain and to promote healing of the ulcer
- Antacids– For symptomatic relief of gastric pain, especially heartburn; will not really promote healing of the ulcers
- Mucosal defense drugs –Have no effect on gastric acid secretion
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What is the Pharmacotherapy for GERD
- Antacids
- H2-receptor antagonists
- Proton pump inhibitors (PPI’s)
- Gastrointestinal stimulant
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What are some lifestyle changes that can be made for patients with GERD
NO Smoking, spicy food, alcohol, caffeine, NSAID’s
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Antacids are used in the treatment of ________ and has what effect on the body
- dyspepsia (indigestion or heartburn)
- Mild to moderate heartburn symptoms
- Neutralize acids in the stomach
- Not the primary drug of choice for treatment
- Do not heal ulcers
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What is an adverse effect that can happen with antacids especially with calcium products
“rebound” hyperacidity
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Sodium bicarbonate:
- Antacid
- (baking soda) combined in many OTC products
- –Contains sodium
- –Sodium is absorbed into general circulation so must minimize use in Na+ restricted diet
- –Alka-Seltzer
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Calcium carbonate:
- Antacid
- –Tums
- –Not absorbed
- –Rebound acid secretion
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(Gaviscon):
- Sodium bicarbonate/alginic acid combination
- Alginic acid is not really an antacid – forms thick solution of sodium alginate (sound familiar?) which floats on the surface of gastric contents – prevents them from contacting the esophagus
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Magnesium hydroxide and aluminum hydroxide combination
- Combining minimizes diarrhea from Mg and constipation from Al
- –Most common antacid: Maalox, Gelusil
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Bismuth subsalicylate (BSS)
- – Pepto-Bismol
- – Suppress H. pylori infection
- – Used in combination with antibiotics
- – Antacid of choice in the treatment and maintenance of PUD
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What is a drug interaction with antacids
- Tums and Maalox, bind with the tetracyclines (tetracycline HCl, minocycline HCl and doxycycline hyclate), and with Fluoroquinolone (Cipro)
- Do not take these antacids together with these antibiotics. Take one to two hours before or after
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What is the mechanism of action of Antihistamines and what is it indicated for
- Inhibit the release of histamine-stimulated gastric acid secretion by blocking the action of histamine on the H2-receptor located on the parietal cell in the stomach
- Effective in healing ulcers in 6 to 12 weeks
- Indicated for the symptomatic relief and healing of ulcers and in alleviating symptoms of duodenal ulcers, gastric ulcers, and gastroesophageal reflux disease (GERD/heartburn)
- Used in conjunction with antibiotics to eradicate H. pylori
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Four H2-receptor antagonists or blockers currently available by prescription and over the counter
- –Cimetidine (Tagamet)
- –Ranitidine (Zantac)
- –Famotidine (Pepcid)
- –Nizatidine (Axid)
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What drug was the First H2-receptor antagonist introduced and what are its drug interactions
- –Inhibits CYP1A2 enzymes in the liver
- Increased levels
- –Tricyclic antidepressants (amitriptyline)
- –Tacrine (anti-Alzheimer’s drug)
- –Antipsychotics (clozapine)
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What is the mechanism of action for PPIs and what are they used for
- Rapid symptomatic relief with accelerating healing of duodenal ulcers, H. pylori infections, and GERD
- Provide long-term and enhanced acid suppression and show high healing rates for PUD
- Bind irreversibly to the proton pump in the membrane of the acid-producing cells in the stomach
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What are the 5 PPIs
- End in “azole”
- Esomeprazole (Nexium)
- Lansoprazole (Prevacid)
- Omeprazole (Prilosec)
- Pantoprazole (Protonix)
- Rabeprazole (AcipHex)
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What are the drug interactions with PPIs and why is that the case and which PPI has the greatest effect
- PPI’s are highly bound to plasma proteins, so there will be displacement of other highly protein-bound drugs (e.g., phenytoin, diazepam, and warfarin)
- Don’t give PPI’s on patient’s taking clopidogrel (Plavix) and aspirin – reduces the antiplatelet effect of these medicines and therefore increases risk of a thromboembolic event
- The above effects are more significant with omeprazole (Prilosec)
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To eradicate Helicobacter pylori in the treatment for PUD what is the drug regimen
use of at least two antibiotics along with an H2 receptor antagonist or a PPI and or bismuth
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What are the three Antibiotic Combination Treatments:Triple therapy (Two-week course)
Omeprazole (Prilosec) OR lansoprazole (Prevacid) + metrodiazole (Flagyl) or amoxicillin + clarithromycin (Biaxin)
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What is the Antibiotic Combination Treatments: Quadruple therapy (Two-week course)
Bismuth subsalicylate (Pepto-Bismol) + metronidazole + tetracyline + H2-antagonist (ex. Zantac) or PPI (ex. Prilosec)
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What is irritable bowel syndrome
- Nonspecific disease with symptoms lasting at least 12 weeks consisting of diarrhea, constipation, and abdominal pain, excessive abdominal distention (bloating)
- Mostly affects women
- Usually starts in adolescence or as young adult
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Diseases associated with IBS
- –chronic stress and anxiety: which comes first, the IBS or the sress?
- –Fibromyalgia or chronic fatigue syndrome, sleep disturbance, migraines
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Treatment of IBS
- Diet
- Exercise
- Stress and anxiety management
- Medication
- Psychological treatment may help in reducing stress and anxiety
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Pharmacologic Treatment of IBS
- Antidiarrheal agents – eg. loperamide (Immodium)
- Antispasmodic/anticholinergic agents – treats the pain and abdominal distention, limited success–eg. Dicyclomine (Bentyl)
- Anticonstipation agents- ex:–Osmotic laxatives – eg. Polyethylene glycol (Miralax)
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what medications are risk factors for constipation
- Calcium channel blockers
- Anticholinergics
- Antacids
- Iron products
- Narcotics – opioid induced constipation
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Constipation treatment
- Bulk-forming agents (fiber) that soften the stool; eg. methylcellulose (Citrucel); psyllium (Metamucil)
- Emollients that soften the stool; eg. docusate sodium (Colace)
- Drugs that cause a soft or semisoft stool eg. senna (Senokot)
- Drugs that cause watery evacuation such as magnesium (Milk of magnesia)
- Osmotic laxatives – eg. Polyethylene glycol (Miralax)
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What are the causes of diarrhea
- –Sign of pathology
- –Contaminated food or water
- –Infection (bacterial, viral, protozoa)
- –Disease (malabsorption syndrome, inflammatory bowel disease such as ulcerative colitis or Crohn’s disease)
- –Immunodeficiency (eg. HIV or AIDS) –Drugs
- –Irritable bowel syndrome
- –Colon carcinoma
- –Traveler’s diarrhea
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Most common bacteria involved in food poisoning are
Salmonella and Escherichia coli (E. coli)
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What are some common antibiotic associated diarrhea
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What is Inflammatory Bowel Disease- Ulcerative Colitis
- Chronic, long-lasting disease resulting in inflammation of the mucosa of the colon (large intestine) and rectum
- Bloody diarrhea and abdominal pain
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Ulcerative Colitis Treatment
- 5-Aminosalicylates (5-ASA)
- Corticosteroids – ex. prednisone
- Antibiotics: ex. metronidazole (Flagyl)
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Patients with ulcerative colitis cannot take
_________ an antibiotic frequently prescribed for dental infections
clindamycin (Cleocin),
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_________ may be a side effect of anticholinergics, antiemetics, and proton pump inhibitors (PPIs),
Xerostomia
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Diarrhea associated with antibiotic use is caused by
Clostridium difficile
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