GERD, PUD, and Stress Ulcers

  1. What is the definition of GERD?
    at least 2 episodes of hearburn per week and/or complications
  2. What is the definition of NERD?
    Presence of troublesome reflux sx but no damage in the esophagus at endoscopy
  3. What is reflux esophagitis?
    inflammation of the esophagus after repeated exposure to stomach contents
  4. What is erosive esophagitis?
    erosion of the esophagus after repeated exposure to stomach contents
  5. What are the causes of GERD?
    • Inappropriate LES relaxation
    • Impaired esophageal clearing
    • Delayed gastric emptying
    • Impaired esophageal mucosal defense
  6. What are the atypical symptoms of GERD?
    • Nonallergic asthma
    • Chronic cough
    • Hoarseness
    • Pharyngitis
    • Chest pain
    • Dental erosions
  7. What are the alarm symptoms of GERD?
    • Continual pain
    • Dysphagia
    • Difficulty swallowing
    • Unexplained wt loss
    • Choking
    • Bleeding
  8. When should an endoscopy be performed for GERD?
    • When atypical or alarm sx are present
    • Pt > 45yo
    • Those refractory to tx
  9. What are some aggravating factors for GERD?
    • Lying down
    • Increased intra-abdominal pressure (Pg, wt)
    • Reduced gastric motility
    • Decreased LES tone
    • Direct mucosal irritation
  10. What are the long-term complications of GERD?
    • Esophageal erosion, ulceration, strictures, or hemorrhage
    • Barrett's esophagitis
    • Reduced QOL
  11. What medications promote GERD by lowering LES tone?
    • Beta agonists
    • Nicotine
    • CCBs
  12. What medications promote GERD by delaying gastric emptying?
    • Narcotics
    • Fatty meals
  13. What medications can cause esophageal injury directly?
    • ASA
    • NSAIDS
    • Bisphosphonates
    • Iron
    • Tomatoes
    • Citrus
    • Alcohol
    • Spicy foods
    • Coffee
  14. What is Step-down treatment for GERD?
    start at high dose PPI and gradually decrease, then switch to H2 antagonist and taper off
  15. What is Step-up treatment for GERD?
    Lifestyle → H2 → PPI → Surgery
  16. What are the antacids used for GERD?
    • Sodium bicarb
    • Calcium carbonate
    • Magnesium salts
    • Aluminum salts
  17. What are the SE of Sodium bicarb?
    • Alkalosis
    • Sodium overload
    • Milk-alkali syndrome (nausea)
  18. What are the SE of Calcium carbonate?
    • Constipation
    • Acid rebound
    • Milk-alkali syndrome (nausea)
  19. What are the SE of magnesium salts?
    • Diarrhea (dose-related)
    • Accumulation of electrolytes in renal failure pts
  20. What are the SE of Aluminum salts?
  21. What is the MOA of antacids in GERD?
    neutralize acid and increase gastric pH → decrease activation of pepsinogen and increase LES pressure
  22. How long should antacids be used to treat GERD?
    no more than 2wks unless a Dr is monitoring your electrolytes
  23. What are the H2 blockers used in GERD?
    • Cimetidine
    • Famotidine
    • Ranitidine
    • Nizatidine
  24. What is the MOA of H2 blockers in GERD?
    Reversibly inhibit H2 receptors on the parietal cell → decreased acid secretion
  25. What are the SE of H2 blockers?
    • CNS (HA, dizziness, fatigue, confusion - elderly at higher risk)
    • Gynecomastia, galactorrhea with prolonged Cimetidine use
    • Decreased platelets/WBC (rare)
    • NVD
    • Constipation
  26. What are the PPIs used in GERD?
    • Omeprazole
    • Lansoprazole
    • Esomeprazole
    • Pantoprazole
    • Rabeprazole
    • Dexlansoprazole
  27. What is the MOA of PPIs in GERD?
    Irreversibly inhibit final step in gastric acid secretion
  28. What are the SE of PPIs?
    • HA
    • Dizziness
    • ND
    • Constipation
    • Possible increased infection rate with C. diff and pneumonia
    • May affect B12 and insoluble Ca absorption
    • Possible risk of fracture with long-term use
  29. How long should H2 blockers be used for GERD?
    8+ weeks
  30. How long should PPIs be used for GERD?
    4-8 wks
  31. Which PPI has the most DI?
    Omeprazole - don't use with Clopidogrel (use H2RA or Pantoprazole or Esomeprazole instead)
  32. What are the promotility agents used in GERD?
    • Metoclopromide
    • Bethanechol
    • Cisapride
  33. What is the MOA of promotility agents in GERD?
    Facilitate increased gastric emptying through a cholinergic mechanism
  34. What are the SE of Metoclopromide?
    • dizziness
    • fatigue
    • somnolence
    • drowsiness
    • EPS
    • Hyperprolactinemia
  35. What are the SE of Bethanechol?
    • Diarrhea
    • Blurred vision
    • Abdominal cramping
    • Possible increase in gastric acid production
  36. What are the SE of Cisapride?
    Cardiac arrhythmia (QT prolongation) when used with 3A4 inhibitors
  37. What are the mucosal protectants used in GERD?
  38. What is the MOA of sucralfate in GERD?
    nonabsorbable aluminum salt coats the stomach
  39. What are the SE of sucralfate?
    accumulation of aluminum in renal failure
  40. When should maintenance therapy for GERD by stopped?
    • When there are no sx for 3mo
    • Possibly try on-demand dosing
  41. What are the types of PUD?
    • Duodenal ulcers
    • Gastric ulcers
  42. What are the causes of ulcers?
    • Duodenal: H. pylori, NSAIDs
    • Gastric: H. pylori, NSAIDS, stress
  43. What is are the differentiating features of duodenal ulcers?
    • Pain worse at night
    • Relieved by eating
  44. What is the differentiating feature of gastric ulcers?
    Pain gets worse with eating
  45. What are the risk factors for NSAID-induced ulcers?
    • Age > 60
    • Increased NSAID dose
    • Longer duration of tx
    • Intrinsic NSAID toxicity
    • Hx of PUD
    • Concurrent use of corticosteroids or anticoagulants
    • Underlying CVD or rheumatologic disease
    • Use of multiple NSAIDs
  46. What are the nonpharmacologic treatments for PUD?
    • Smoking cessation
    • D/C NSAIDs and ASA
    • Decrease stress
    • Avoid food that exacerbate sx
  47. What is the treatment for H. pylori PUD?
    • Amoxicillin + Clarithromycin + Tinidazole or Metronidazole + PPI x 14d
    • Amoxicillin + PPI for 5d, then Clarithromycin + Tinidazole or Metronidazole + PPI for 5d
    • Amoxicillin + PPI for 7d, then Amoxicillin + Clarithromycin + Tinidazole or Metronidazole for 7d
    • Bismuth + Tetracycline + Tinidazole or Metronidazole + PPI for 10-14d
  48. What is the preferred duration of therapy for H. pylori PUD?
  49. How do NSAIDs cause ulcers?
    Inhibition of prostaglandins and direct irritation
  50. How do you treat NSAID-induced ulcers?
    • Remove or lower the NSAID dose
    • Try a selective NSAID or COX2 inhibitor (won't heal any faster)
    • Add a PPI, H2RA, or Sucralfate - heals in 6-8wks
  51. What are the partially selective NSAIDs?
    • Etodolac
    • Meloxicam
    • Diclofenac
    • Celecoxib
    • Nabumitone
  52. What is the DOC for healing and prevention of PUD?
    PPIs or Misoprostol
  53. What are the doses used for PUD?
    • Omeprazole 20-40mg
    • Lansoprazole 15-30mg
    • Esomeprazole 20-40mg
    • Pantoprazole 40mg
    • Rabeprazole 20mg
    • Dexlansoprazole 30-60mg
    • Sucralfate 1g QID or 2g BID
  54. What are the SE of Misoprostol?
    • Diarrhea
    • Abdominal pain
    • Nausea
    • Flatulence
  55. What are the CI for Misoprostol?
  56. What should you do if sx of PUD persist for > 8wks (duodenal) or > 12wks (gastric) despite tx?
    Increase dose of PPI (may require maintenance tx with a healing dose)
  57. What is the tx for Zollinger-Ellison syndrome (ZES)?
    • PPI (high dose)
    • Octreotide
    • Surgery
    • Chemotherapy
  58. What are the causes of an Upper GI Bleed?
    • PUD
    • Esophagitis
    • Erosive disease
    • Esophageal varices
    • Stress ulcers
  59. What are the sx of an Upper GI bleed?
    • Hematemesis
    • NVD
    • Melena (bloody stool)
    • Hypotension
  60. What is the tx for an Upper GI Bleed?
    • Cauterize the bleed
    • Remove blood thinners
    • PPI (high dose bolus + continuous infusion for 72hrs)
  61. How are stress ulcers different from PUD?
    • Multiple ulcers
    • Lack of chronic inflammation
    • Asymptomatic
  62. What are the risk factors for stress ulcers?
    • Mechanical ventilation for > 48hrs (or anticipated to be)
    • Coagulopathy (INR > 1.5 without Warfarin)
    • GI bleeding/ulceration within last yr
  63. What is can be used for prevention of stress ulcers?
    • Antacids
    • H2RA
    • PPI
    • Sucralfate
  64. What is DOC for prevention of stress ulcers?
    H2RA (cheaper, many routes available including NG feeding possible which may help by increasing use of the gut)
  65. When should stress ulcer prophylaxis be discontinued?
    • When pt transferred out of ICU
    • Extubation
    • Oral intake initiated
    • Consider if < 2 risk factors
Card Set
GERD, PUD, and Stress Ulcers
GERD, PUD, and Stress Ulcers