Question 1

Dyspepsia;
ROME III definition

Accepted Answer

Presence of 1 or more dyspepsia symptoms that are considered to originate from the gastroduodenal region, in the absence of any organic, systemic, or metabolic disease that is likely to explain the symptoms.

Question 2

GERD: What

Accepted Answer

Problem with Lower esophageal sphincter

Question 3

GERD s&s:

Accepted Answer

Symptoms usually occur when pH <4.
Heartburn (retrosternal/epigastric): frequent and persistent
Also, regurgitation, fullness, belch, nausea.
Episodic or at HS.
Aggravated by recumbent position & eating.
Alleviated by antacids.

Question 4

GERD Atypical S&S:

Accepted Answer

Atypical (extra-esophageal)
wheeze, cough, hoarse, sore throat, ear ache, poor dentition, CP.

Question 5

GERD Alarm symptoms; Refer

Accepted Answer

dysphagia, odynophagia, choking, bleeding, wt loss, anemia, persistent vomiting, anorexia, fever.

Question 6

GERD; When to refer for EGD

Accepted Answer

GI referral should be considered in patients over 50 yrs old with new onset.
Red flags.
Symptoms persist >2 wks of treatment.
Concurrent use of NSAIDS.
For FNP: kids and pregnant women.

Question 7

GERD; Non Pharm Tx

Accepted Answer

Lifestyle modifications;
Lose weight (lower fat intake).
Stop smoking.
limit ETOH and fatty/aggravating foods.
HOB up; no supine for 3hrs postprandial.

Question 8

GERD; Non Pharm Tx

Accepted Answer

Eliminate possible offending agents (ETOH, chocolate, coffee, onion, garlic).
Eliminate offending meds. 
Smooth muscle relaxants can worsen pbms.

Question 9

GERD; Goals of Pharm tx

Accepted Answer

Goals: ACID SUPPRESSION to protect mucosa and:
↑ LES, gastric empty, acid clearance.
↓ reflux, volume.

Question 10

GERD: Pharm Tx Antacids

Accepted Answer

Antacids: stop acid now and protect mucosa; ↑ LES pressure
PRN (maalox, mylanta, tums), OTC trial for 2 weeks.

Question 11

GERD Pharm Tx: Mild

Accepted Answer

H2 Blockers: Initial choice. decrease gastric acid.
Cimetidine, famotidine, nizatidine, ranitidine: all available OTC.
Prn dosing for mild vs. scheduled dosing.
Standard dosing for 6-12 wks for mod.
High dosing for 8-12 weeks for severe.

Question 12

GERD Pharm Tx:  Severe

Accepted Answer

PPI: initial choice for severe GERD. (more expensive than H2RA)
Esomeprazole,, lansoprazole, omeprazole, pantoprazole, rabeprazole.
4-8 wks for mild-mod.
8-16 wks for severe.

Question 13

GERD Pharm Tx: Severe

Accepted Answer

Prokinetic/motility agents: for selected pts as adjunct to acid suppression. 
Metoclopramide is an alternative to H2RA but more SE; avoid in the elderly.

Question 14

PUD: What?

Accepted Answer

Two main causes PUD: 
NSAIDs.
H. pylori infection.

Question 15

PUD: Symptoms

Accepted Answer

Gnawing, burning epigastric pain (vs.heartburn, which is predominant in GERD).
Relieved with food or antacids.
Awakens pt at night or between meals when stomach is empty (2/3 duodenal ulcer).
Bloating and abdominal fullness.

Question 16

PUD Symptoms

Accepted Answer

Waterbrash (rush of saliva after regurgitation to dilute the acid in esophagus). 

Nausea/vomiting. 
Appetite and weight loss. 
Hematemesis and/or melena (tarry, foul-smelling feces due to oxidized iron from hemoglobin).

Question 17

PUD Refer

Accepted Answer

GI bleeding, obstruction, anemia, weight loss, perforation, malignancy, or new onset dyspepsia in persons older than 50.

Question 18

PUD TX:

Accepted Answer

When PUD from NSAID, stop taking NSAID; begin taking PPI (symptoms resolve w/in 2 wks).

Question 19

PUD H. Pylori: Diagnostic Testing

Accepted Answer

Decision based on:
$, need for rapid results.
Probability of current active v. previously eradicated infection.
Test for exposure (detect antibodies)
Serologic testing
Use for initial diagnosis but not after treatment to confirm cure

Question 20

PUD H. Pylori: Diagnostic Testing 
Active Infection Testing

Accepted Answer

Test for active infection:
Fecal antigen test.
Urea breath test.

Question 21

PUD H. Pylori: Diagnostic Testing 
Active Infection Testing

Accepted Answer

Test for exposure (detect antibodies);
Serologic testing.
Use for initial diagnosis but not after treatment to confirm cure.  If have never been treated for it, then treat them.

Question 22

PUD Tx: 
If H. Pylori

Accepted Answer

Start triple therapy.
Continue PPI or H2 RA for 4-8 wks to promote healing.

Question 23

PUD Tx:
Triple Therapy

Accepted Answer

PPI based triple therapy 10-14d:
PPI and
Clarithromycin  500mg tid,and
Metronidazole 500mg tid (pcn allergy) or
Amoxicillin. 
Conventional triple therapy
Bismuth 2tabs qid, and
Metronidazole  250mg qid or tid, and
Tetracycline 500mg qid.

Question 24

PUD Tx:
Non H.Pylori

Accepted Answer

PPI (preferred if complicated ulcer);
4 wk (duodenal); 8 wk (gastric).
Or H2RI (less expensive);
6 wk (duodenal); 8wk (gastric).
If pt w/ PUD needs short-term NSAID, gastroprotective tx w/ PPI.

ComPbms.ABD

GERD, PUD, Dyspepsia

Question	Answer
Dyspepsia; ROME III definition	Presence of 1 or more dyspepsia symptoms that are considered to originate from the gastroduodenal region, in the absence of any organic, systemic, or metabolic disease that is likely to explain the symptoms.
GERD: What	Problem with Lower esophageal sphincter
GERD s&s:	Symptoms usually occur when pH <4. Heartburn (retrosternal/epigastric): frequent and persistent Also, regurgitation, fullness, belch, nausea. Episodic or at HS. Aggravated by recumbent position & eating. Alleviated by antacids.
GERD Atypical S&S:	Atypical (extra-esophageal) wheeze, cough, hoarse, sore throat, ear ache, poor dentition, CP.
GERD Alarm symptoms; Refer	dysphagia, odynophagia, choking, bleeding, wt loss, anemia, persistent vomiting, anorexia, fever.
GERD; When to refer for EGD	GI referral should be considered in patients over 50 yrs old with new onset. Red flags. Symptoms persist >2 wks of treatment. Concurrent use of NSAIDS. For FNP: kids and pregnant women.
GERD; Non Pharm Tx	Lifestyle modifications; Lose weight (lower fat intake). Stop smoking. limit ETOH and fatty/aggravating foods. HOB up; no supine for 3hrs postprandial.
GERD; Non Pharm Tx	Eliminate possible offending agents (ETOH, chocolate, coffee, onion, garlic). Eliminate offending meds. Smooth muscle relaxants can worsen pbms.
GERD; Goals of Pharm tx	Goals: ACID SUPPRESSION to protect mucosa and: ↑ LES, gastric empty, acid clearance. ↓ reflux, volume.
GERD: Pharm Tx Antacids	Antacids: stop acid now and protect mucosa; ↑ LES pressure PRN (maalox, mylanta, tums), OTC trial for 2 weeks.
GERD Pharm Tx: Mild	H2 Blockers: Initial choice. decrease gastric acid. Cimetidine, famotidine, nizatidine, ranitidine: all available OTC. Prn dosing for mild vs. scheduled dosing. Standard dosing for 6-12 wks for mod. High dosing for 8-12 weeks for severe.
GERD Pharm Tx: Severe	PPI: initial choice for severe GERD. (more expensive than H2RA) Esomeprazole,, lansoprazole, omeprazole, pantoprazole, rabeprazole. 4-8 wks for mild-mod. 8-16 wks for severe.
GERD Pharm Tx: Severe	Prokinetic/motility agents: for selected pts as adjunct to acid suppression. Metoclopramide is an alternative to H2RA but more SE; avoid in the elderly.
PUD: What?	Two main causes PUD: NSAIDs. H. pylori infection.
PUD: Symptoms	Gnawing, burning epigastric pain (vs.heartburn, which is predominant in GERD). Relieved with food or antacids. Awakens pt at night or between meals when stomach is empty (2/3 duodenal ulcer). Bloating and abdominal fullness.
PUD Symptoms	Waterbrash (rush of saliva after regurgitation to dilute the acid in esophagus). Nausea/vomiting. Appetite and weight loss. Hematemesis and/or melena (tarry, foul-smelling feces due to oxidized iron from hemoglobin).
PUD Refer	GI bleeding, obstruction, anemia, weight loss, perforation, malignancy, or new onset dyspepsia in persons older than 50.
PUD TX:	When PUD from NSAID, stop taking NSAID; begin taking PPI (symptoms resolve w/in 2 wks).
PUD H. Pylori: Diagnostic Testing	Decision based on: $, need for rapid results. Probability of current active v. previously eradicated infection. Test for exposure (detect antibodies) Serologic testing Use for initial diagnosis but not after treatment to confirm cure
PUD H. Pylori: Diagnostic Testing Active Infection Testing	Test for active infection: Fecal antigen test. Urea breath test.
PUD H. Pylori: Diagnostic Testing Active Infection Testing	Test for exposure (detect antibodies); Serologic testing. Use for initial diagnosis but not after treatment to confirm cure. If have never been treated for it, then treat them.
PUD Tx: If H. Pylori	Start triple therapy. Continue PPI or H2 RA for 4-8 wks to promote healing.
PUD Tx: Triple Therapy	PPI based triple therapy 10-14d: PPI and Clarithromycin 500mg tid,and Metronidazole 500mg tid (pcn allergy) or Amoxicillin. Conventional triple therapy Bismuth 2tabs qid, and Metronidazole 250mg qid or tid, and Tetracycline 500mg qid.
PUD Tx: Non H.Pylori	PPI (preferred if complicated ulcer); 4 wk (duodenal); 8 wk (gastric). Or H2RI (less expensive); 6 wk (duodenal); 8wk (gastric). If pt w/ PUD needs short-term NSAID, gastroprotective tx w/ PPI.

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