NSAIDs damage the gastroduodenal mucosa by two mechanisms, and the systemic COX-1 mechanism is the one that matters for prevention: no topical avoidance protects the mucosa. The risk factors are the teaching point because they do not add, they multiply, and the H. pylori interaction compounds them. The case. A 70-year-old on daily NSAIDs and low-dose aspirin with a prior ulcer presents with a new gastric ulcer. Beyond stopping the NSAID, what does the risk-factor stack tell you about prevention going forward? Topics covered NSAID mechanism: systemic COX-1 inhibition strips prostaglandin-driven mucosal defense Why the systemic mechanism means enteric coating does not protect Multiplicative risk factors: age over 65, prior ulcer, high-dose or multiple NSAIDs, anticoagulation, steroids The H. pylori and NSAID interaction: two pathways that compound PPI co-prescription as the primary prevention strategy in high-risk patients COX-2 selective agents: GI benefit versus cardiovascular cost Refractory ulcers: exclude persistent H. pylori, occult NSAID use, ZES, and malignancy Zollinger-Ellison: fasting gastrin, secretin stimulation, and the off-PPI caveat Gastric ulcers require follow-up to confirm healing and exclude cancer Complications: bleeding, perforation, and gastric outlet obstruction Key decisions Every high-risk patient who must stay on an NSAID gets a co-prescribed PPI: risk factors multiply, so a stacked patient is high-risk even without a prior ulcer Enteric coating and rectal or IV routes do not protect the stomach: NSAID injury is systemic through COX-1, not topical A refractory ulcer triggers a specific checklist: confirm H. pylori eradication, hunt occult NSAID/aspirin use, check fasting gastrin for ZES, and biopsy to exclude malignancy Gastric ulcers get a follow-up endoscopy to document healing and rule out cancer; duodenal ulcers usually do not Fasting gastrin for suspected ZES must be interpreted off PPI, because acid suppression itself raises gastrin For the full chapter with MCQs, tables, and primary-guideline references, visit www.boardpearls.com. Questions or feedback: [email protected]. (00:00) - Opening: the systemic NSAID mechanism (02:30) - Multiplicative risk factors (05:30) - PPI co-prescription and COX-2 tradeoffs (08:30) - Refractory ulcers and the exclusion checklist (12:00) - Zollinger-Ellison and fasting gastrin (15:00) - Complications: bleeding, perforation, obstruction

Ask this episode

“What did the council decide on item 42?” — answered with the speaker and the moment.

Transcript

Related