Title: Peptic ulcer disease
1PEPTIC ULCER DISEASE
- Dr. W.C. Lwabby (MMed, MD)
- Lecturer Int. Med.Dept
-
2Learning Objectives
- To define peptic ulcer disease(PUD)
- To describe the pathophysiology of PUD
- To discuss the diagnosis of PUD
- To describe the treatment of PUD
3Gastric Mucosa Secretions
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5Hydrochloric Acid Production
- 1. CO2 and Cl- diffuse from the
- blood into the stomach cell.
- 2. CO2 combines with H2O
- to form H2CO3.
- 3. H2CO3 dissociates into
- bicarbonate (HCO3-) and H.
- 4. H combines with Cl- in duct
- of gastric gland to form HCl-.
- 5. An ATP pump is necessary to
- pump the HCl- into the duct
- since the concentration of
- HCl- is about a million times
- more concentrated in the
- duct than in the cytosol of the
- cell.
6Introduction
- The inside of the stomach is bathed in about 2L
of gastric juice daily. - Gastric juice is composed of
- Digestive enzymes Concentrated hydrochloric
acid - which can readily tear apart the toughest food
or microorganism - The gastroduodenal mucosal integrity is
determined by - Protective (defensive)
- Damaging (aggressive) factors
7Introduction..
- The Defensive Forces
- Bicarbonate
- Mucus layer
- Mucosal blood flow
- Prostaglandins
- Growth factors
- The Aggressive Forces
- Helicobacter pylori
- HCl acid
- Pepsins
- NSAIDs
- Bile acids
- Ischemia and hypoxia.
- Smoking and alcohol
- When the aggressive factors increase or the
defensive factors decrease, - Mucosal damage will result, leading to erosions
ulcerations.
8Introduction..
- Definition
- Peptic Ulcer
- An ulcer of the alimentary tract mucosa, usually
in the - Stomach
- Duodenum
- Lower esophagus( rarely),
- where the mucosa is exposed to the acid gastric
secretion - It has to be deep enough to penetrate the
muscularis mucosa
9Peptic Ulcer Disease
10Pathophysiology
- A peptic ulcer is a mucosal break,
- 3mm or greater in size with depth.
- Two major variants in peptic ulcers are commonly
encountered in the clinical practice - Duodenal Ulcer (DU)
- Gastric Ulcer (GU)
11Pathophysiology
- DU results from increased acid load to the
duodenum due to - Increased acid secretion because of
- Increased parietal cell mass
- Increased gastrin secretion,
- (e.g. Zollinger-Ellison syndrome, alcohol
spicy food) - Decreased inhibition of acid secretion,
- possibly by H. pylori damaging somatostatin-produc
ing cells in the antrum - Smoking impairing gastric mucosal healing
- Genetic susceptibility may play a role
- HCO3 secretion is decreased in the duodenum by H.
pylori inflammation
12Pathophysiology..
- GU results from the break down of gastric mucosa
- Associated with gastritis affecting the body
the antrum - The local epithelial damage which occurs because
of - Cytokines released from H. pylori
- Abnormal mucus production
13Etiology
- The two most common causes of PUD are
- Helicobacter pylori infection ( 70-80)
- Non-steroidal anti-inflammatory drugs (NSAIDS)
- Other uncommon causes include
- Gastrinoma (Gastrin secreting tumor)
- Stress ulceration (trauma, burns, critical
illness) - Vascular insufficiency
14Pathogenesis of H. pylori in PUD
- H. pylori
- Is Gram-negative and spiral
- Has multiple flagella at one end,
- which make it motile,
- allowing it to live deep beneath the mucus layer
where the pH is close to neutral
15Pathogenesis of H.pylori in PUD.
- Any acidity is buffered by
- Organism's production urease enzyme,
- which catalyzes production of ammonia (NH3) from
urea raises the pH - The bacterium stimulates chronic gastritis by
- provoking a local inflammatory response.
16Effects of H. pylori on gastric Hormones
17Pathogenesis of NSAIDS in PUD
- Symptomatic GI ulceration occurs in 2 - 4 of
patients treated with NSAIDs for 1 year. - The effects of aspirin other NSAIDs on the
gastric mucosa, - ranges from mucosal hemorrhages to erosions
acute ulcers - NSAIDs inhibits the production of prostaglandins
precursor from membrane fatty acids resulting in - Decrease mucus HCO3 production
- Decrease mucosal blood flow
- Reduce cell renewal
- The drugs also generate oxygen-free radicals
-
- Products of the lipoxygenase pathway may
contribute to ulceration
18Pathogenesis of NSAIDS in PUD
- Gastric acid probably aggravates NSAID-induce
mucosal injury by - Converting superficial injury to deeper mucosal
necrosis - Interfering with haemostasis platelet
aggregation - Impairing ulcer healing
- Users of NSAIDs,
- are at approximately 3 times greater relative
risk of serious adverse gastrointestinal events
than non-users
19Clinical Presentation
- Recurrent epigastric pain (the most common
symptom) - Burning
- Relieved by food ? DU
- Precipitated by food ? GU
- Relieved by antacids
- Radiate to back (consider penetration)
- Pain may be absent or less characteristic in
one-third of patients especially in elderly
patients on NSAIDs
20Clinical Presentation
- Nausea, Vomiting
- Chest discomfort
- Anorexia, weight loss especially in GU
- Hematemesis or melena resulting from Upper GI
bleeding
21Investigations
- Diagnosis of ulcer
- History
- In most patients routine laboratory tests are
unhelpful - Diagnosis of PUD depends mainly on endoscopic and
radiographic confirmation - Diagnosis of H. pylori
- Laboratory tests (Stool, breath serology)
22Doudenal Ulcer on Endoscopy
23Diagnosis of H. pylori
- Non-invasive
- C13 or C14 Urea Breath Test
- Stool antigen test
- H. pylori IgG titer (serology)
- Invasive
- Gastric mucosal biopsy from OGD
- Rapid Urease test
24Non-invasive
-
- C13 or C14 Urea Breath Test
The best test for the detection of an active
infection
25What is the basis of this test?
- Is based on the ability of H. pylori to break
down urea into carbon dioxide, - which then is absorbed from the stomach and
eliminated in the breath.
26How is this breath test done?
- Patients swallow a capsule containing urea made
from an isotope of carbon. - If H. pylori is present in the stomach,
- the urea is broken up and turned into carbon
dioxide. - The carbon dioxide is absorbed across the lining
of the stomach and into the blood. - It then travels in the blood to the lungs,
- Â where it is excreted in the breath.
- Samples of exhaled breath are collected,
- the isotopic carbon in the exhaled carbon
dioxide is measured.
27How are the results of the urea breath test
interpreted?
- If the isotope is detected in the breath,
- it means that H. pylori is present in the
stomach. - If the isotope is not found, H. pylori is not
present. - When the H. pylori is effectively treated
(eradicated) by antibiotics, - the test changes from positive (isotope present)
to negative (isotope absent).
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30Non-invasive
- Serology for H pylori
- Serum Antibodies (IgG) to H pylori
- (Not for active infection)
- Fecal antigen testing
- Test for active HP
31Invasive
- Upper GI endoscopy
- Highly sensitive test
- Patient needs sedation
- Has both diagnostic therapeutic roles
- Diagnostic
- Detect the site and the size of the ulcer,
- even small and superficial ulcer can be detected
- Detect severity of the ulcer like bleeding
- Biopsies can be taken for,
- rapid urease test, histopathology culture
32Rapid urease test ( RUT)
- Gastric biopsy specimens are placed in the rapid
urease test kit. - If H pylori are present,
- bacterial urease converts urea to ammonia, which
changes pH and produces a COLOR change
33- Infection should be considered as present when
any test is positive - Both the invasive tests the breath test should
be negative to establish the absence of
infection.
34PUD Complications
- Bleeding Upper GI bleeding
- Perforation-Peritonitis
- Gastric outlet or duodenal obstruction
- Chronic anemia
35Treatment Goals
- Rapid relief of symptoms
- Healing of ulcer
- Preventing ulcer recurrences
- Reducing ulcer-related complications
- Reduce the morbidity (including the need for
endoscopic therapy or surgery) - Reduce the mortality
36General Strategy
- Treat complications aggressively if present
- Determine the etiology of ulcer
- Discontinue NSAID use if possible
- Eradicate H. pylori infection if present or
strongly suspected, - even if other risk factors (e.g., NSAID use) are
also present) - Smoking cessation should be encouraged
-
37Drugs Therapy
- H2-Receptors antagonists bd for 6-8 weeks, can
heal DU 90. -
- Proton pump inhibitors
- Cyto-protective agents
- Prostaglandin agonists
- Antacids
- Antibiotics for H. pylori eradication
38H2-Receptors AntagonistsAgents
- Cimetidine 800mg OD or 400mg BID
- Ranitidine 300mg OD or 150mg BID
- Famotidine 40mg OD or 20mg BID
- Nizatidine 300mg OD or 150mg BID
- Should be taken for 6-8 weeks
39 Proton Pump Inhibitors (PPIs)
- Omeprazole 20mg
- Lansoprazole 30mg
- Pantoprazole 40mg
- Rabeprazole 20mg
- Esomeprazole 40mg
40Antacids
- Antacids contain either
- Sodium-bicarbonate
- Aluminum-hydroxide
- Magnesium-hydroxide
- Calcium carbonate
- Require large neutralizing capacity,
- a single dose of 156 meq antacid given 1 hr
after meal effectively neutralize gastric acid
for 2 hr, - a second dose given 3 hr after eating maintains
the effect for over 4 hr after the meal
41 H. Pylori Eradication Therapy
- Until recently,
- the recommended duration of therapy for H.pylori
eradication was 10 -14 days - There are number of recent studies evaluated
one-, five-, seven-day regimens - Regimens for eradication of H. pylori infection ar
e typically chosen empirically, - on the basis of regional bacterial resistance
patterns, local recommendations, and drug
availability. - They include
- Triple therapy
- Nonbismuth quadruple therapy
- Bismuth-based therapy
- Levofloxacin-containing therapy
- Second-line therapy
- Rescue or third-line therapy
42Triple therapy
- Remains an option for first-line therapy in areas
of low clarithromycin resistance (lt15) - Consists of the following
- Proton pump inhibitor (PPI) (eg, omeprazole 20 mg
BID, lansoprazole 30 mg BID) - Clarithromycin 500 mg BIDÂ Â (first-line) or
metronidazole 500 mg BIDÂ (when clarithromycin
resistance is increasing) - Amoxicillin 1000 mg BID or metronidazole  (if not
already selected) - 14 days is the optimal duration of triple therapy
43Nonbismuth quadruple therapy
- May be given sequentially or concomitantly.
- Sequential therapy
- Is superior to standard triple therapy
- Consists of the following
- PPI plus amoxicillin for 5-7 days then
- PPI plus 2 other antibiotics for the next 5-7
days, - clarithromycin and metronidazole are the
antibiotics usually chosen - Concomitant therapy
- consists of the following
- PPIÂ plus
- Amoxicillin plus
- Clarithromycin plus
- Metronidazole
44Heligo Kit
- Heligo Kit contains
- Clarithromycin, Lansoprazole, and Tinidazole as
active ingredients. - It improves the patient's condition by performing
the following functions - Killing bacteria and reducing the infection.
- Inhibiting the protein's production in bacteria
to stop the bacterial growth. - Decreasing the amount of acid made in the stomach
45- Patients with Peptic ulcers usually require,
- 3 to 4 weeks further treatment with a proton
pump inhibitors after eradication therapy. - The effectiveness of treatment should be assessed
symptomatically. - If symptoms persist,
- a C13 urea breath test or stool test for H.
pylori should be performed to check eradication.
46REFERENCES
- Brian R, Walker N, Stuart H. Davdsons Principle
and Practice of Medicine 22nd Edition. Peptic
ulcer disease, pg 872-879. - KASPER F,HAUSER LONGO. HARRISONS PRINCIPLES OF
INTERNAL MEDICINE 19th Edition. Peptic ulcer
disease and related disorders pg 2438-2452.
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