GERD (gastroesophageal reflux disease)
Only screen for H. pylori in the case of PUD, history of documented peptic ulcer disease or gastric mucosa-associated lymphoma. No endoscopy needed unless there are alarm symptoms.
- Avoid alcohol, caffeine, chocolate, citrus, garlic, onions and mint
- Reduce fat
- Avoid eating 2-3 hours before bedtime
- Remain upright for 2 hours after meals
- Weight loss
- Discontinue nicotine
- Elevate the head of the bed
- Avoid tight-fitting clothes
- Avoid meds that lower LES (alpha antagonists, calcium channel blockers, anticholinergics, theophylline, BZDs, opiates) or delay gastric emptying (opiates, tricyclic antidepressants, calcium channel blockers, progesterone) or irritate stomach (NSAIDs, ASA, corticosteroids)
- In patients without evidence of erosion, start with OTC antacids. Move up to PPIs.
- Erosive esophagitis must be treated for at least 8 weeks with PPIs. Treat for 4 weeks if no erosion.
- Can add promotility agents with diagnostic evaluation.
Peptic Ulcer Disease:
- Usually H. pylori (see treatment). NSAIDS (ibuprofen, diclofenac are less toxic than naproxen)
- PPIs are the preferred gastroprotective agents for treatment and prevention of NSAID-associated GI injury. Higher risk in 1st 3 months of NSAID use.
- Naproxen is the only NSAID with no cardiovascular risk. Less likely to have GI effects than some.
- Misoprostol is effective for healing and secondary prevention of NSAID induced ulcers, but more GI side effects than PPI. Misoprostol has a sulfa moiety.
- Cox-2 inhibitors should be used as last line therapy. Increase cardiovascular risk, decrease GI toxicity
- Ibuprofen attenuates aspirin antiplatelet effects. Space ibuprofen 30 minutes before or 8 hours after ASA.
- The first step is volume resuscitation with a crystalloid or colloid if hemoglobin < 7.
- Endoscopy withing 12-24 hours.
- Remove meds contributing to bleeding, and start PPI therapy. Do not use H2R2 or octreotide.
- Test for H Pylori.
- IV PPI bolus and drip for 72 hours. Oral PPI for 8 weeks.
- DC both aspirin and clopidogrel. Monitor for ischemic events. Hold until bleed is resolved.
Stress Ulcer Prophylaxis:
- Only for patients who are in the ICU when:
- been on the vent for greater than 48 hours
- <50,000 platelets
- thermal injury
- severe head or spinal cord injury
- GI bleed in past year
- low intragastric pH
- major surgery lasting more than 4 hours
- acute lung injury
- Or at least two of the below:
- ICU stay exceeds one week
- occult bleeding
- high dose steroids
- hepatic failure
- acute renal insufficiency
- Treatment: Antacids, sucralfate, H2RA or PPIs