GERD, PUD, and Stress Ulcers
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What is the definition of GERD?
at least 2 episodes of hearburn per week and/or complications
What is the definition of NERD?
Presence of troublesome reflux sx but no damage in the esophagus at endoscopy
What is reflux esophagitis?
inflammation of the esophagus after repeated exposure to stomach contents
What is erosive esophagitis?
erosion of the esophagus after repeated exposure to stomach contents
What are the causes of GERD?
- Inappropriate LES relaxation
- Impaired esophageal clearing
- Delayed gastric emptying
- Impaired esophageal mucosal defense
What are the atypical symptoms of GERD?
- Nonallergic asthma
- Chronic cough
- Chest pain
- Dental erosions
What are the alarm symptoms of GERD?
- Continual pain
- Difficulty swallowing
- Unexplained wt loss
When should an endoscopy be performed for GERD?
- When atypical or alarm sx are present
- Pt > 45yo
- Those refractory to tx
What are some aggravating factors for GERD?
- Lying down
- Increased intra-abdominal pressure (Pg, wt)
- Reduced gastric motility
- Decreased LES tone
- Direct mucosal irritation
What are the long-term complications of GERD?
- Esophageal erosion, ulceration, strictures, or hemorrhage
- Barrett's esophagitis
- Reduced QOL
What medications promote GERD by lowering LES tone?
- Beta agonists
What medications promote GERD by delaying gastric emptying?
What medications can cause esophageal injury directly?
- Spicy foods
What is Step-down treatment for GERD?
start at high dose PPI and gradually decrease, then switch to H2 antagonist and taper off
What is Step-up treatment for GERD?
Lifestyle → H2 → PPI → Surgery
What are the antacids used for GERD?
- Sodium bicarb
- Calcium carbonate
- Magnesium salts
- Aluminum salts
What are the SE of Sodium bicarb?
- Sodium overload
- Milk-alkali syndrome (nausea)
What are the SE of Calcium carbonate?
- Acid rebound
- Milk-alkali syndrome (nausea)
What are the SE of magnesium salts?
- Diarrhea (dose-related)
- Accumulation of electrolytes in renal failure pts
What are the SE of Aluminum salts?
What is the MOA of antacids in GERD?
neutralize acid and increase gastric pH → decrease activation of pepsinogen and increase LES pressure
How long should antacids be used to treat GERD?
no more than 2wks unless a Dr is monitoring your electrolytes
What are the H2 blockers used in GERD?
What is the MOA of H2 blockers in GERD?
Reversibly inhibit H2 receptors on the parietal cell → decreased acid secretion
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)
What are the PPIs used in GERD?
What is the MOA of PPIs in GERD?
Irreversibly inhibit final step in gastric acid secretion
What are the SE of PPIs?
- Possible increased infection rate with C. diff and pneumonia
- May affect B12 and insoluble Ca absorption
- Possible risk of fracture with long-term use
How long should H2 blockers be used for GERD?
How long should PPIs be used for GERD?
Which PPI has the most DI?
Omeprazole - don't use with Clopidogrel (use H2RA or Pantoprazole or Esomeprazole instead)
What are the promotility agents used in GERD?
What is the MOA of promotility agents in GERD?
Facilitate increased gastric emptying through a cholinergic mechanism
What are the SE of Metoclopromide?
What are the SE of Bethanechol?
- Blurred vision
- Abdominal cramping
- Possible increase in gastric acid production
What are the SE of Cisapride?
Cardiac arrhythmia (QT prolongation) when used with 3A4 inhibitors
What are the mucosal protectants used in GERD?
What is the MOA of sucralfate in GERD?
nonabsorbable aluminum salt coats the stomach
What are the SE of sucralfate?
accumulation of aluminum in renal failure
When should maintenance therapy for GERD by stopped?
- When there are no sx for 3mo
- Possibly try on-demand dosing
What are the types of PUD?
- Duodenal ulcers
- Gastric ulcers
What are the causes of ulcers?
- Duodenal: H. pylori, NSAIDs
- Gastric: H. pylori, NSAIDS, stress
What is are the differentiating features of duodenal ulcers?
- Pain worse at night
- Relieved by eating
What is the differentiating feature of gastric ulcers?
Pain gets worse with eating
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
What are the nonpharmacologic treatments for PUD?
- Smoking cessation
- D/C NSAIDs and ASA
- Decrease stress
- Avoid food that exacerbate sx
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
What is the preferred duration of therapy for H. pylori PUD?
How do NSAIDs cause ulcers?
Inhibition of prostaglandins and direct irritation
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
What are the partially selective NSAIDs?
What is the DOC for healing and prevention of PUD?
PPIs or Misoprostol
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
What are the SE of Misoprostol?
- Abdominal pain
What are the CI for Misoprostol?
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)
What is the tx for Zollinger-Ellison syndrome (ZES)?
- PPI (high dose)
What are the causes of an Upper GI Bleed?
- Erosive disease
- Esophageal varices
- Stress ulcers
What are the sx of an Upper GI bleed?
- Melena (bloody stool)
What is the tx for an Upper GI Bleed?
- Cauterize the bleed
- Remove blood thinners
- PPI (high dose bolus + continuous infusion for 72hrs)
How are stress ulcers different from PUD?
- Multiple ulcers
- Lack of chronic inflammation
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
What is can be used for prevention of stress ulcers?
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)
When should stress ulcer prophylaxis be discontinued?
- When pt transferred out of ICU
- Oral intake initiated
- Consider if < 2 risk factors
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