Peptic Ulcer DiseaseDr. Wael H. Mansy, MDAssistant ProfessorCollege of Pharmacy King Saud University2009

Define the following terms: peptic ulcer, gastric ulcer, Discuss the different etiologic factors of PUDList the role of H.pylori as the main cause of PUD. Describe the role of each of these specific cells in the immune response.Discuss the different diagnostic methods of PUDDiscuss the complications of PUDDiscuss the treatment of PUD

Peptic ulcerrefers to erosion of the mucosa lining any portion of the G.I. tract.It is defined as : A circumscribed ulceration of the gastrointestinal mucosa occurring in areas exposed to acid and pepsin and most often caused by Helicobacter pylori infection. (Uphold & Graham, 2003)gastric ulcer : the ulcer that occurs in the stomach lining ,some of them may be malignantduodenal ulcer : most often seen in first portion of duodenum (>95%)Peptic Ulcer Disease (PUD)Definition

NormalEsophagus & Stomach

Protective factors vs. hostile factors

Etiology of PUD A) Normal B) Increased Attack *Hyperacidity*Pepsin.*NSAIDs.C) Weak defense *Helicobacter pylori *Stress, drugs, smoking

Peptic ulcer disease

The causes of peptic ulcer disease include the following: Infection with the bacteria Helicobacter pylori occurs in 80 to 95% of patients with peptic ulcer disease. H. pylori infection impairs the protective mechanisms of the G.I. tract against low pH and digestive enzymes and leads to ulceration of the mucosa. Stress Emotional, trauma, surgical. Injury or death of mucus-producing cells. Excess acid production in the stomach. The hormone gastrin stimulates the production of acid in the stomach; therefore, any factors that increase gastrin production will in turn increase the production of stomach acid.Drugs: Chronic use of aspirins and NSAIDs, or Corticosteroids

ETIOLOGIC FACTORS OF PUD

Most common infection in the world (20%)10% of men, 4% women develop PUDPositive in 70-100% of PUD patients.H.pylori related disorders:Chronic gastritis 90%Peptic ulcer disease 95-100%Gastric carcinoma 70%Gastric lymphomaReflux Oesophagitis.Non ulcer dyspepsiaHelicobacter pylori:

Helicobacter pylori:

Duodenal Ulcer Vs. Gastric Ulcer

Manifestations of peptic ulcer disease: Episodes of remission and exacerbation Pain that for duodenal ulcers is often relieved by eating or antacids G.I. bleeding and possible hemorrhage (20 to 25% of patients) Perforation of ulcers with significant mortality Obstruction of G.I. tract

EndoscopyBarium meal contrast x-rayBiopsy bacteria & malignancyH.Pylori:Endoscopy cytologyBiopsy Special stainsCulture - difficultUrease Breath test.PUD - Diagnosis

Urease Breath Test.

Bleeding Chronic, Acute, MassiveFibrosis, Stricture obstruction pyloric stenosis.Perforation Peritonitis- emergency.Gastric carcinoma. (not duodenal carcinoma)

PUD Complications

Non-pharmacological Treatment of Peptic ulcer1-Avoid spicy food.2-Avoid xanthin containing beverges.3-Avoid Alcohol.4-Avoid Smoking.5-Avoid heavy meals.6-Encourage small frequent low caloric meals.7-Avoid ulcerating drugs e.g. NSAIDs, corticosteroids, xanthines and parasympathomimetics

Triple therapy for 14 days is considered the ttt of choice. Proton Pump Inhibitor + clarithromycin and amoxicillin Omeprazole (Prilosec): 20 mg PO bid for 14 d or Lansoprazole (Prevacid): 30 mg PO bid for 14 d or Rabeprazole (Aciphex): 20 mg PO bid for 14 d or Esomeprazole (Nexium): 40 mg PO qd for 14 d plus Clarithromycin (Biaxin): 500 mg PO bid for 14 and Amoxicillin (Amoxil): 1 g PO bid for 14 dCan substitute Flagyl 500 mg PO bid for 14 d if allergic to Penicillin.In the setting of an active ulcer, continue on proton pump inhibitor therapy for additional 2 weeks.Goal: complete elimination of H. Pylori. Once achieved reinfection rates are low. PUD Treatment

Reference listFantry, G. T. (2005, May 6). Peptic Ulcer Disease. Retrieved September 4th, 2006, from www.emedicine.com/med/topic1776.htmGeneral Practice Notebook (2006). Peptic Ulcer. Retrieved September 10th, 2006, from www.gpnotebook.co.uk/simplepage.cfm?ID=630849536Microbe Wiki (2006, August 16). Heliobacter. Retrieved September 10th, 2006, from www.microbewiki.kenyon.edu/index.php/HelicobacterMoore, R. A. (1995). Helicobacter pylori and peptic ulcer: A systematic review of effectiveness and an overview of the economic benefits of implementing what is known to be effective. Oxford: Cortecs Limited and Health Technology Evaluation Association.Pounder, R. (1994). Peptic ulceration. Medicine International, 22:6, 225-30. Rodney, W.M. (2005, Summer). H. Pylori eradication options for peptic ulcer. Nurse Practitioners Prescribing Reference,12(2), 150. Uphold, C. R. & Graham, M. V. (2003). Clinical Guidelines in Family Practice (4th ed.). Gainesville, FL: Barmarrae Books, Inc.

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