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home - Stomach - Peptic Ulcer Disease - NSAID Primary And Secondary Prevention Written by Dr Sebastian Zeki
Knowledge

Knows the range of organic and non-organic causes of dyspepsia. Be
aware of current BSG and NICE guidelines for selecting patients for
investigation. Know the significance of alarm symptoms
Understands the relevance of Helicobacter pylori infection and how it
can be detected and treated.
Recognise the adverse effect of nonsteroidal anti-inflammatory drugs
Understands the physiology of gastric acid secretion, mucosal
protection and gastroduodenal motility and know how drugs can
modify these
Knows the complications of ulcer disease, the principles of surgery
that may be required and be aware of post-operative sequelae

Skills
Makes a thorough clinical assessment, perform appropriate
investigations and be familiar with how medical treatments are used.
Show awareness of how to recognise and manage complications

Behaviours
Can explain the steps taken towards making a diagnosis and
planning treatment clearly and comprehensibly

Also....

Knowledge
Knows the causes of upper gastrointestinal bleeding and its
presentation
Understands the circulatory disturbance associated with blood loss
and the pathophysiology underlying the clinical manifestations of
hypovolaemic shock
Knows the principles of assessing hypovolaemia and of restoring the
circulation. Be able to identify and correct coagulopathy
Knows the principles of using the various risk stratification tools SCE 1
Knows how endoscopic techniques are used to control bleeding CbD, DOPS, SCE 1
Understands how oesophageal and gastric varices develop and the
endoscopic and pharmacological methods that are used to control
blood loss

Skills
Can make an accurate clinical assessment, and stratify the risk. Know
the principles of fluid resuscitation and arrange endoscopy
Is aware of methods to secure haemostasis, recognise signs of rebleeding and liaise with other disciplines (such as interventional
radiology or surgery

Behaviours
Assesses and treats patients who have bleeding with appropriate
degree of urgency.

Also...
Knowledge


Understands why part or all of the patient’s stomach is removed and
the altered post-surgical anatomy

Understands the problems of a gastro-enterostomy and a Roux-en-y
anastomosis

Has awareness of dumping syndromes
Knows the various surgical operations performed for obesity (bariatric
surgery) and their complications

Skills
Can give nutritional advice and choose the appropriate method by
which an enteral feeding tube is inserted into the small bowel

Can initiate the use of pancreatic enzyme therapy
Has ability to recognise and treat early and late dumping syndrome
Behaviours
Able to help the patient carers friends and family understand how
the patient can be encouraged to gain weight

Works closely with dieticians and surgical colleagues

NSAID Primary And Secondary Prevention

Prevention Strategies Use misoprostol (prostaglandin E analog) together with a nonselective NSAID. Use PPI together with a nonselective NSAID . Use a selective COX-2 inhibitor with or without a PPI. High risk patients= These patients have a previous complicated ulcer (especially recent) or >2 other risk factors Low risk patientsThese are classified as having no risk factors Moderate risk patients These patients have 1-2 risk factors High risk CV patientsThese are patients requiring low-dose aspirin. No NSAIDs, including COX-2 inhibitors. COX-2 inhibitor and PPI or misoprostol. Low risk CV COX-2 inhibitor alone or a conventional NSAID + PPI or misoprostol. Naproxen (is cardioprotective) and PPI or misoprostol. Conventional NSAID alone, although the "least ulcerogenic NSAID at the lowest effective dose" Naproxen (is cardioprotective) and PPI or misoprostol. All patients regardless of risk who are about to start long-term traditional NSAID therapy should be considered for testing for H. pylori and treated if positive. With continued NSAID therapy — If had ulcer, then treatment dose PPI for 4-8 weeks, then maintenance for NSAID durationEradicate H. pyloriPatients who had a previous ulcer and who must resume NSAID/aspirin- give PPI (lansoprazole/esomeprazole)Esomeprazole is also effective in preventing celecoxib-induced bleeding ulcers.COX-2 selective NSAID with PPI prevent recurrent ulcers but CVS riskDouble dose PPI not more effective than single dose PPI for prophylaxis NSAIDs (including aspirin): Primary and Secondary prevention of gastroduodenal toxicity Misoprostol gives absolute risk reduction of 0.57 Can cause diarrhoea- reduce by introducing at 100µg tds then slowly up to 200µg qds Have slightly lower efficacy than misprostol in this context Are more effective than H2 antagonists Primary Prevention Selective COX2 InhibitorsReduced risk of PUD but still have risk.Aspirin increases risk when used concurrently, to that of a non-selective NSAID.Warfarin with COX-2 increases hospitalization with GI bleed to same level as non-selective NSAIDs. Enteric-coated and buffered aspirinIt reduces endoscopic signs but not risk of bleeding as bleeding related to systemic effect. Role of Helicobacter PyloriTest and treat H. pylori if have ulcer before starting NSAIDs.If the patient is asymptomatic or there is no PUD history, can test and treat if you like. Secondary Prevention Written by Dr Sebastian Zeki

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