Causes of PUD
- h. pylori
- medications such as NSAIDs, SAS and glucocorticoids
- more common in men
- duodenal ulcers between ages 30-55
- gastric ulcers between ages 55-65
- alcohol and dietary factors DO NOT seems to cause ulcers
Signs and Symptoms PUD
Duodenal: relief with eating
Gastric: pain worsens with eating
Physical findings of PUD
- mild epigastric tenderness
- Gi bleeding (20%): Melena, hematemesis
- Perforation (5-10%): severe epigastric pain, board like and, rigidity-rare
Labs and diagnostics of PUD
- may see anemia on cbc
- consider endoscopy after 2-8 weeks tx
- H. Pylori testing
Outpatient management PUD with PPI or H2 receptor antagonist
H2 receptor antagonists: -tagamet 800mg Ranitidine (zantac) -Famotidine (pepcid) -Axid start with these and give at night more expensive than PPI
PPI:
-Lansoprazole etc
if H2 blockers don’t work then work to PPI
Mucosal protective agent: given 2 hours apart from other meds
-sucralfate (requires acidic environment-avoid antacids and H2 blockers)
is a/w decreases in nonsocomial pna
Bismuth (pepto)
- direct antibacterial action against H, pylori
- promotes prostaglandic production/stimulates gastric bicarbonate
Misoprostol 4x daily with food
-used as prophylaxis against NSAID induced ulcers
-stimulates mucous and bicarb production
-may stimulate uterine contraction**
-PPI in pts who cannot discontinue NSAIDs
H2 blockers, sucralfate, and antacids do not prevent NSAID-induced ulcers
Antacids (mylanta, maalox, MOM) do not reduce the amount of gastric acidity
H. Pylori eradication therapy
must use combo therapy
- resistance develops quickly to flagyl and clarithromycin
- does not develop quickly to amoxicillin or tetracycline
Combo options: 2 abx and a PPI or bismuth
-flagyl 500 bid with omeprazole 20 bid and clarithromycin 500 bid
- amox 1 g daily, ompeprazole 20 bid and clarith 500 bid
- flagyl 500 bid, omeprazole 20 bid and amox 1 g bid for 7-14 days
after abx therapy continue PPI then switch to H2
Bismuth regimens for H. Pylori
four times daily and have more side effects
-bismuth 2 tabs, flagyl 250 and tetracycline 500
or the above regimen plus omeprazole 20 mg bid x 7 days
Inpatient management of PUD
- cbc, pt/ptt, bmp
- endoscopy
- bladder catheter
- npo,ng tube
- upright decub films show free air in 75% of cases
- monitor abd
- IV H2 blockers
- if coagulopathy present give FFP
- if thrombocytopenia < 50,000 transfuse platelets
- GI eval
GERD. what is it?
a disorder characterized by the back flow (reflux) of acidic gastric contents into the esophagus.
- imcompetent lower esophageal sphincter
- delayed gastric emptying
S & S GERD
- retrosternal burning
- bitter taste in mouth
- belching, dysphagia
- excessive salvation
- frequently occurs at night or in recumbent position
- may be relieved by sitting u p, antacids, water or food
Diagnostics of GERD
referal for esophagogastroduodenoscopy (EGD): R/O cancer, Barrett’s esophagus, PUD etc
Management GERD non pharmacological
-elevated HOB
-avoid alc and caffeine, spices, peppermint
-stop smoking
weight reduction
Management GERD pharmacological
- antacids PRN
- H2 blockers (tidiness) in high doses at night or decided twice daily
- PPI if H2 blockers ineffective
- GI surgical consult PRN
