GERD, PUD, GI Bleeding

GERD is due to lower esophageal sphincter (LES) contraction or relaxation?

relax

USUAL symptoms of GERD → 3

heartburn, regurgitation, belching

ALARM symptoms of GERD → 4

1. dysphagia (difficulty swallowing)

2. odynophagia (pain swallowing)

3. bleeding

4. weight loss

Presence of Alarm symptoms OR risk factors for Barrett’s esophagus

1. ______ = 1st line

2. ______ can be collected during procedure

1. EGD

2. biopsy

DIAGNOSIS: If typical symptoms of GERD, trial PPI therapy

1. Responsive to therapy →

2. Unresponsive to therapy →

1. GERD

2. EGD after 2-4 weeks off PPI → if normal, esophageal reflux (pH) monitoring

GERD: NON-PHARM COUNSELING

1. __________ of bed

2. __________

3. Avoid _____________

4. Include ___________ meals in diet

5. Eat _________

6. Avoid _____________

7. Stop ________

8. Avoid ________

9. Avoid __________

10. Always take drugs ______________

1. elevate head

2. -weight

3. irritating foods

4. protein-rich

5. small meals

6. sleeping immediately after meals

7. smoking

8. alcohol

9. tight fitting clothes

10. sitting upright/standing w plenty of liquid

GERD Pharm agents (7)

1. antacids

2. H2RAs

3. PPIs

4. sucralfate

5. prokinetic

6. baclofen

7. vonoprazan

ANTACIDS

Provide rapid symptom relief (<5 min)

1. Used as __________________________ for immediate symptom relief

2. short duration of action → requires ______

3. DDIs → 4

4. _________ combination serves as protective barrier for esophagus against gastric contents and -freq of reflux of episodes, may be superior to antacid alone

1. adjunct therapy to PPI/H2RA

2. freq admin

3. TCN, ferrous sulf, sulfonylureas, quinolone ABs

4. alginic acid

H2RAS

1. Low-dose, OTC H2RAs or standard doses given BID may be beneficial for _____ GERD

2. Patients not responding may be hypersecretors and require ________

3. BUT more cost-effective and effective to switch to ______

4. indications → 2

5. ADMINISTRATION → 3

6. DDIs → Many interxns with _______ / CYP450

7. Precautions →

1. mild

2. higher doses

3. PPI

4. alone for mild, at bedtime adjunct to PPI for nocturnal symptoms

5. at onset, 30-60 min before, or BID w/o regard to meals

6. cimetidine

7. renal/advanced age dose adj

PPIs

1. rapid symptom relief and ___________ in mod-sev GERD

2. Recommended ________ for troublesome symptoms

3. PPIs can interfere with the _____ of certain drugs

4. Formulations?

5. ADEs → 4

6. AVOID ABRUPT DC → If receiving continuous therapy _____, taper over _____ (-50% every week)

   Add H2RA/antacid during taper if needed

1. higher healing rates

2. empirically

3. abs

4. DR cap/tab

5. C diff, fractures, vit B12 def, blocks clopidogrel (CYP2C19 inhib)

6. >6 month → 3-8 weeks

SUCRALFATE (CARAFATE)

1. MOA:

2. ADEs → 2

3. DDIs →

4. ONLY RECOMMENDED FOR ..

1. mucosal protective agent

2. constipation, bloating

3. take other meds 2h before or 6h after

4. GERD in pregnancy

2 agents →

1. ONLY recommended for …

1. GERD + gastroparesis

2. metoclopramide/Reglan, prucalopride/Motegrity

BACLOFEN

1. MOA:

2. ADEs → 3

   *Consider trial of baclofen if symptoms despite optimal PPI therapy

1. GABA agonist

2. dizzy, somnolence, constipation

VONOPRAZAN (VOQUEZNA)

1. MOA: __________ → -gastric acid secretion

2. Approved for _________ (superior to lansoprazole)

3. Cost?

1. blocks K+ binding to PP

2. erosive esophagitis

3. EXPENSIVE

Erosive Esophagitis / Barrett’s Esophagus

1. 1st line + duration

2. 2nd line + duration

3. PPI indefinitely OR ___________ for LA grade C or D Erosive esophagitis

1. PPI → 8-12 weeks EE, 6-12 months maintenance

2. vonoprazan → 8 weeks EE, 6 months maintenance

3. anti-reflux surgery

REFRACTORY GERD

1. Persistent symptoms AFTER ______ of double-dose PPI

2. Best approach is to …

3. Treatment → 6

1. 8-12 weeks

2. Optimize PPI therapy

3. daily PPI → reassess 8-12 wks → confirm timing 30-60 min b4 meals → BID PPI → +H2RA bedtime → switch PPI

GERD PHARM MONITORING

1. Antacids / H2RAs

2. PPIs

3. General → 2

1. renal, sx after 2 weeks

2. hepatic, sx after 8 weeks

3. DDIs, develop of alarm/extraesophageal sx

Which of the following represents an alarm GERD symptom?

a. Regurgitation

b. Chronic cough

c. Dysphagia

d. Heartburn

C

Which of the following drugs is considered a risk factor for the development of bone fractures?

a. Metoclopramide

b. Famotidine

c. Rabeprazole

d. Alginic acid

C

When attempting to deprescribe PPI therapy, which of the following is an appropriate recommendation? Select ALL that apply.

a. Adding an H2RA when the PPI is discontinued

b. Changing to an immediate-release PPI formulation

c. Overlapping an H2RA with PPI therapy before discontinuation

d. Tapering down to the lowest dose that controls symptoms

A, C, D

The preferred initial treatment option for a 45-year-old male presenting with a 1-week history of GERD symptoms is:

a. Promotility agent

b. Proton-pump inhibitor

c. Anti-reflux surgery

d. Endoscopic therapy

B

Which of the following is a potential adverse effect of long-term PPI therapy?

a. Hypercalcemia

b. Clostridium difficile infection

c. Vitamin A deficiency

d. Hypokalemia

B

A 47-year-old man did not achieve resolution of symptoms on omeprazole 40mg BID. GERD diagnosis was confirmed. What is appropriate?

a. Confirm timing at start of meal

b. Switch to baclofen

c. Add cimetidine

d. Taper PPI

C (next step is +H2RA at bedtime)

Which of the following is/are appropriate initial treatment options for a patient with erosive esophagitis noted on endoscopy? Select ALL that apply.

a. famotidine for 12 weeks

b. pantoprazole for 10 weeks

c. vonoprazan for 8 weeks

d. baclofen for 6 months

B, C

Common causes of chronic ulcers → 3

1. H pylori

2. NSAIDs

3. critical illness (stress)

Differential Diagnosis

1. GERD →

2. PUD →

1. burning, exacerbated by some foods

2. pain/discomfort abdomen, relieved by eating/drinking

ULCER COMPARISON

H pylori vs NSAID-induced

1. H pylori → duodenum > stomach, superficial

2. NSAID → stomach > duodenum, deep

PUD: NON PHARM

1. ________ reduction

2. -

3. Avoidance of foods causing dyspepsia →

1. stress/anxiety

2. smoking cessation

3. caffeine, spicy, alcohol, etc

H PYLORI

1. _______ bacterium with flagella that has urease, catalase, and oxidase activity

2. Urease →

3. Catalase → survive reactive oxidation by phagocytes → causes ______

4. Some patients have dyspepsia or GERD symptoms → expect only ______ improv w H pyloria tx

1. gram -

2. converts urea → ammonia → neutralizes gastric acid

3. inflam

4. modest

H PYLORI DIAGNOSIS

1. If alarm symptoms or risk factors for peptic ulcer/gastric cancer →

2. Gold standard, tests for active infxn →

3. Tests for AB resistance, use if fail 1st line tx →

4. Active infxn →

5. Only used in research →

6. DOESN’T differentiate btwn active vs cured infxn →

7. Active infxn, 95% sens + specific →

8. Active infxn, similar accuracy ^

1. endoscopy

2. histology stain

3. culture

4. biopsy urease

5. PCR

6. AB

7. urea breath test → withhold PPI/H2RA 1-2 wks prior, ABs/bismuth 4 wks

8. fecal antigen → ^

What is the recommended agent for H pylori treatment in a patient w Penicillin allergy?

BQT (optimized bismuth quadruple)

PUD 1ST LINE THERAPY OPTIONS (3)

Regimen + duration + drugs

1. BQT → 14d → PPI + bismuth + metronidazole + TCN

2. Rifabutin triple → 14d → omeprazole + amoxicillin + rifabutin

3. PCAB dual → 14d → vonoprazan → amoxicillin

PUD: Test of Cure

1. _____________________ recommended

2. Should be performed at least ______ after regimen completion

1. biopsy, UBT, or fecal antigen

2. 4 weeks

55-year-old patient with iron-deficiency anemia, GERD, and gastric cancer (in remission) taking ferrous sulfate, famotidine, pantoprazole, and aspirin. How should he be tested for H. pylori? Select ALL that apply.

A. Polymerase chain reaction

B. Urea breath test

C. Fecal antigen

D. Histology stain

D

Which is a correct instruction for a patient undergoing urea breath test (UBT)?

Select ALL that apply.

A. Stop sucralfate 3 weeks prior

B. Stop cimetidine 2 weeks prior

C. Stop dexlansoprazole 4 weeks prior

D. Stop bismuth subsalicylate 1 week prior

B

38-year-old patient with UBT + for H. pylori. Her current medical problems include acne, PUD, and HTN. Current medications include omeprazole, doxycycline, and amlodipine. NKDA. What is the best treatment option?

A. Rifabutin triple

B. Optimized BQT

C. PCAB dual

D. Levofloxacin triple

B (BQT is the strongest rec 1st line)

She comes back 4 weeks later for test of cure. Her UBT once again comes back positive. What is appropriate therapy now?

A. Rifabutin triple

B. Optimized BQT

C. PCAB dual

D. Levofloxacin triple

A

Which NSAIDs are COX2 selective? (4)

1. celecoxib

2. nabumetone

3. etodolac

4. meloxicam

RISK FACTORS FOR NSAID-ASSOCIATED PUD

Concomitant use of … (6)

1. NSAID + low dose ASA

2. oral bisphos

3. corticosteroids

4. anticoagulants

5. antiplatelets

6. SSRIs (fluox, parox, sert, etc)

PUD: NSAIDS-ASSOC TREATMENT

1. -

2. Admin …

3. IF must give NSAID →

4. If symptoms unresolved after …

1. stop NSAID

2. H2RA, PPI, or sucralfate x 8 weeks

3. COX2 selective + PPI/misoprostol

4. 8 weeks → test H pylori → tx if +

MISOPROSTOL

1. MOA:

2. Must be dosed ________

   Effect is dose-related

3. ADEs → 2

4. Important note

1. PGE1 analog

2. TID-QID

3. N/D, abdominal cramping

4. TERATOGENIC

37-year-old taking meloxicam 15 mg daily for chronic knee pain is diagnosed with PUD. Which is appropriate treatment?

A. Bismuth subsalicylate x 8 weeks

B. Pantoprazole x 4 weeks

C. Famotidine x 8 weeks

D. Misoprostol x 4 weeks

C

What pain regimen should be initiated after PUD treatment?

A. Acetaminophen + ibuprofen

B. Diclofenac + sucralfate

C. Continue meloxicam at lower dose

D. Celecoxib + omeprazole

D

IDIOPATHIC ULCERS TREATMENT →

May need long-term maintenance therapy d/t high recurrence rates

PPI/H2RA x 8 weeks