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GIT Management — Study Preparation

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1. PEPTIC ULCER DISEASE (PUD) ⭐ (Priority Topic)

Pathophysiology Recap

• Imbalance between mucosal protective factors (mucus, bicarbonate, prostaglandins, blood flow) and aggressive factors (HCl, pepsin, H. pylori, NSAIDs)
• H. pylori accounts for ~70% of duodenal ulcers and ~50% of gastric ulcers
• NSAIDs (COX inhibition → ↓ prostaglandins) are the second major cause

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H. pylori Eradication Regimens

🔵 Triple Therapy (Classic — now less preferred)

If penicillin allergy: Replace amoxicillin with Metronidazole 500 mg BID ⚠️ Eradication rates have dropped to <80% in many regions due to rising clarithromycin resistance (>15–20%). Triple therapy is no longer the preferred first-line empiric regimen per ACG 2024 guidelines.

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🟠 Bismuth Quadruple Therapy (BQT) — Now Preferred First-Line (ACG Guidelines)

✅ 14 days is superior to 10 days for eradication rates ✅ Preferred when antibiotic susceptibility is unknown ✅ Achieves ~85–90% eradication even in clarithromycin-resistant strains ❌ Complex regimen (many pills) → adherence challenge

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How We Switch / Replace Regimens — Substitution Rules

TREATMENT-NAIVE (susceptibility unknown):
  ├─ First choice → Bismuth Quadruple Therapy × 14 days
  ├─ No penicillin allergy, no BQT available → Rifabutin Triple Therapy
  └─ Alternative → P-CAB dual therapy (vonoprazan + amoxicillin) × 14 days

TREATMENT-EXPERIENCED (first treatment failed):
  ├─ Not previously on optimized BQT → Use optimized BQT × 14 days
  ├─ Previously on BQT → Rifabutin Triple Therapy × 14 days
  └─ Salvage (culture/susceptibility guided) → Levofloxacin-based regimen
       (PPI + Levofloxacin 500 mg OD + Amoxicillin 1 g BID × 14 days)

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🔴 Salvage / Third-Line Options

⚠️ Clarithromycin or levofloxacin salvage regimens should NOT be used empirically if prior exposure occurred (resistance highly likely)

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When to Use Which — Summary Table

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Non-H. pylori PUD (NSAID-induced)

1. Stop NSAID if possible
2. PPI — first-line for healing (omeprazole 20–40 mg OD × 4–8 weeks)
3. Misoprostol (prostaglandin analog) — add if NSAID must be continued
4. Switch to COX-2 selective inhibitor (celecoxib) — less ulcerogenic
5. Test-and-treat for H. pylori in all PUD patients regardless of cause

Complications of PUD

• Bleeding → IV PPI bolus + infusion, endoscopic hemostasis
• Perforation → emergency surgery (Graham patch repair)
• Obstruction → endoscopic dilation or surgery
• Malignancy → all gastric ulcers must be biopsied + followed to healing

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2. DYSPLASIA (GIT Context)

Definition

Classification

Barrett's Esophagus — Dysplasia Management

• No dysplasia → PPI + surveillance endoscopy every 3–5 years
• LGD → PPI + endoscopic ablation (radiofrequency ablation, RFA) preferred; surveillance every 6 months
• HGD → Endoscopic eradication therapy (RFA, EMR, cryotherapy); esophagectomy if endoscopic therapy fails
• Key principle: Confirm dysplasia with two expert pathologists before acting

IBD-Associated Dysplasia

• Risk increases with duration, extent, and severity of colitis
• Chromoendoscopy is preferred surveillance technique
• Visible dysplasia → Endoscopic Mucosal Resection (EMR)
• Invisible/multifocal HGD → Proctocolectomy

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3. ULCERATIVE COLITIS (UC)

Disease Extent Classification

• Proctitis — rectum only
• Left-sided colitis — to splenic flexure
• Extensive/pancolitis — beyond splenic flexure

Management by Severity

Mild–Moderate UC

Moderate–Severe UC

Acute Severe UC (Truelove & Witts Criteria)

≥6 bloody stools/day + ≥1 systemic sign (fever, tachycardia, anemia, elevated ESR/CRP)

1. Admit to hospital
2. IV corticosteroids (hydrocortisone 100 mg QID or methylprednisolone 60 mg/day)
3. Assess response at 72 hours
4. No response → Rescue therapy: Infliximab (5 mg/kg) OR Ciclosporin (2 mg/kg IV)
5. Still no response → Colectomy (subtotal colectomy with ileostomy)

Surgery in UC — Indications

• Refractory disease / steroid dependence
• Dysplasia / colorectal cancer
• Acute severe UC not responding to medical therapy
• Procedure: Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA/J-pouch) — curative

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4. CROHN'S DISEASE

Key Differences from UC

Management

Induction

Maintenance

Special Situations

• Fistulizing disease → Infliximab + azathioprine (combination superior)
• Perianal fistula → Seton placement + infliximab; examine under anesthesia
• Stricture → Balloon dilation (endoscopic) or strictureplasty
• Surgery → Resection of severely affected segment (ileocecal most common); bowel-sparing principles

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5. QUICK COMPARISON — IBD vs. PUD

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High-Yield Exam Points

1. BQT is now preferred over triple therapy as first-line empiric H. pylori treatment (ACG 2024)
2. 14 days > 10 days for all H. pylori regimens
3. Never repeat a failed regimen — always switch antibiotic class
4. Clarithromycin resistance >20% in most regions — reason triple therapy fell out of favor
5. Penicillin allergy → in triple therapy, swap amoxicillin → metronidazole; in quadruple, already metronidazole-based
6. Rifabutin triple = go-to salvage when BQT has been tried
7. UC is continuous from rectum; Crohn's has skip lesions
8. UC surgery is curative; Crohn's surgery is not curative
9. Acute severe UC: IV steroids → 72h assessment → infliximab/ciclosporin rescue → colectomy
10. Dysplasia in IBD: visible → EMR; invisible HGD/multifocal → proctocolectomy

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