Discuss differential diagnosis of Acute Gastritis, Esophageal Cancer, Hiatal Hernia and Helicobacter Pylori Infection.
Peer 1

Discussion Question 1

1. What would you prescribe initially?

Eradication of H. pylori is critical to PUD treatment, all recommended treatment regimens include a combination of a PPI and antimicrobial therapy (Woo et al., 2020). Antimicrobial agents used include clarithromycin, tetracycline, amoxicillin, levofloxacin, and metronidazole (Woo et al., 2020). If H. pylori clarithromycin resistance in the local area is less than 15%, the first-line therapy is a PPI, clarithromycin, and amoxicillin or metronidazole for 14 days in patients with no previous history of macrolide exposure for any reason (Woo et al., 2020). There are different treatment regimens depending on each individual case but most patients will be started on Abx and PPI.

2. How long would you prescribe these medications?

Most antimicrobial treatment will be for 5-14 days depending on antimicrobial that works best for the patient and the different elements that go along with the dx of H. pylori. Probiotics have also been found to improve eradication rates in patients being treated for Helicobacter pylori (Woo et al., 2020). Current guidelines follow a step-down approach, and treatment is begun with a proton pump inhibitor (PPI) (Woo et al., 2020). PPI treatment will continue even after infection is eradicated, 8 to 12 weeks until healing completes. Possible Daily use of PPI for high-risk patients (Woo et al., 2020).

3. What other possible meds could you prescribe to assist with the side effects from the medications prescribed?

Patients can be given triple or quadruple drug regimen that includes bismuth subsalicylate (Woo et al., 2020) But adverse drug reactions have been reported in up to 70% of patients taking bismuth-based four-drug regimens (Woo et al., 2020).Probiotics have also been found to improve eradication rates in patients being treated. Lifestyle modifications and antiacids can also help with the underlying disease.

4. How would the treatment vary if the patient has GERD instead?

GERD results from the reflux of chyme from the stomach into the esophagus (Woo et al., 2020). Drugs can be used to increase LES tone, reduce the amount of acid in the chyme, improve peristalsis and thereby decrease the time chyme is available to produce reflux, and decrease the exposure of the mucosa to highly acid material (Woo et al., 2020). Goal for GERD includes reduce or eliminate the symptoms, heal any esophageal lesions, manage or prevent complications such as stricture, Barrett’s esophagus, or esophageal carcinoma; and prevent relapse. Meeting these goals requires a combination of lifestyle modification and drug therapy (Woo et al., 2020). Mild GERD symptoms are treated with OTC antiacids to control symptoms, Moderate to severe GERD is treated with Lifestyle changes, PPI for 8 weeks (Woo et al., 2020). Reevaluation is required after a few weeks for further treatment. Lifestyle changes include but not limited to taking PPI or antiacids 30-60 mins prior to eating or drinking anything. Do not lay down after meals, do not eat or drink anything before bedtime and Smoking cessation (Woo et al., 2020).

Discussion Question 2

Differential Diagnosis: Acute Gastritis, Esophageal Cancer, Hiatal Hernia, Helicobacter Pylori Infection.

GERD results from the reflux of chyme from the stomach into the esophagus (Woo et al., 2020). Drugs can be used to increase LES tone, reduce the amount of acid in the chyme, improve peristalsis and thereby decrease the time chyme is available to produce reflux, and decrease the exposure of the mucosa to highly acid material (Woo et al., 2020). Goal for GERD includes reduce or eliminate the symptoms, heal any esophageal lesions, manage or prevent complications such as stricture, Barrett’s esophagus, or esophageal carcinoma; and prevent relapse. Meeting these goals requires a combination of lifestyle modification and drug therapy (Woo et al., 2020). Mild GERD symptoms are treated with OTC antiacids to control symptoms, Moderate to severe GERD is treated with Lifestyle changes, PPI for 8 weeks (Woo et al., 2020). Reevaluation is required after a few weeks for further treatment. Lifestyle changes include but not limited to taking PPI or antiacids 30-60 mins prior to eating or drinking anything. Do not lay down after meals, do not eat or drink anything before bedtime and Smoking cessation (Woo et al., 2020).

Testing for GERD: No testing if symptoms are “straightforward” GERD. If the patient does not respond to treatment with twice daily PPI, Endoscopy is recommended (Woo et al., 2020). Follow up with GI specialist as well for alarming symptoms to include melena, persistent vomiting, weight loss, anemia, hematemesis etc (Woo et al., 2020).

Reference:

Woo, T. M., Wynne, A. L., & Robinson, M. V. (2020). Pharmacotherapeutics for Advanced. Practice Nurse prescribers. F.A. Davis Company.