treatment and other aspects of peptic ulcers and GERD

1. Peptic Ulcer And
GERD
Krupanidhi College of Pharmacy,
Bangalore
Presented By-
Bhavya Rewari
M.Pharm. IstYear
Dept. of Pharmacology
1

2. Peptic Ulcer Disease
2

3. Definition and Introduction
 Peptic ulcer is a chronic lesion that occurs in any
portion of the GIT (usually stomach) exposed to the
aggressive action of acid-peptic juices
 At least 98 % of peptic ulcers are in the upper portion of
the duodenum
 Peptic ulcer disease mainly comprises of painful sores or
ulcers in the lining of the stomach or first part of the
small intestine, called the duodenum
 A peptic ulcer in the stomach is called a gastric ulcer. An
ulcer in the duodenum is called a duodenal ulcer
3

4. Definition and Introduction
 It causes disruption of the mucosal integrity of the stomach,
duodenum, or both caused by local inflammation, which leads
to a well-defined mucosal defect
 Peptic ulcers are relapsing lesions that most often diagnosed
in middle-aged to older adults
 Duodenal ulcers are more frequent in patients with
alcoholic cirrhosis, COPD and chronic renal failure
 Normally, the lining of the stomach and small intestines is
protected against the irritating acids produced in the stomach.
If this protective lining stops working correctly and the lining
breaks down, it results in inflammation (gastritis) or an ulcer.
4

5. Pathogenesis
5
 The imbalance between defensive mechanism and
aggressive factors (gastric acid and pepsin and H. pylori)
Defensive mechanism include;
• Secretion of mucus by epithelial cells
• Secretion of bicarbonate which act as buffer
• Rapid gastric epithelial regeneration
• Mucosal blood flow to sweep away hydrogen ion

6. Pathogenesis
6
Aggressive factors;
• Secretion of gastric HCl from the parietal cells
• Secretion of pepsin
• Presence of H.pylori which survives in the gastric mucosal
layer
Agents that increase the complications-
• NSAIDs drug therapy
• Cigarette smoking
• Alcohol
• Corticosteroids therapy

7. 7

8. 8

9. Signs and symptoms
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• Epigastric pain
• The pain tends to be worse at night and occurs 1 to 3 hrs
after meals
• Nausea
• Vomiting
• Belching
• Significant weight loss
• Complications of hemorrhage occurs in one-third patients
• Feeling of fullness - unable to drink as much fluid
• Pain or discomfort in the upper abdomen
• Bloody or dark tarry stools

10. Some common causes
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 Drinking too much alcohol
 Regular use of aspirin, ibuprofen, naproxen, or other
nonsteroidal anti-inflammatory drugs (NSAIDs
 Smoking cigarettes or chewing tobacco
 Being very ill, such as being on a breathing machine
 Having radiation treatments
 A rare condition called Zollinger-Ellison syndrome causes
stomach and duodenal ulcers. Persons with this disease
have a tumor in the pancreas. This tumor releases high
levels of a hormone that increases stomach acid.

11. 11

12. Treatment
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 Treatment involves a combination of medications to kill the H.
pylori bacteria (if present), and reduce acid levels in the
stomach.
 This strategy allows your ulcer to heal and reduces the chance
of a relapse
 If one has a peptic ulcer with an H. pylori infection, the standard
treatment uses different combinations of the following
medications for 5 - 14 days:
 Two different antibiotics to kill H. pylori, such as clarithromycin
(Biaxin), amoxicillin, tetracycline, or metronidazole (Flagyl)
 Proton pump inhibitors such as omeprazole (Prilosec),
lansoprazole (Prevacid), or esomeprazole (Nexium)
 Bismuth (the main ingredient in Pepto-Bismol) may be added
to help kill the bacteria

13. Treatment
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 If one has an ulcer without an H. pylori infection, or one
that is caused by taking aspirin or NSAIDs, the doctor will
likely prescribe a proton pump inhibitor for 8 weeks
 Other medications that may be used for ulcer symptoms
or disease are:
• Misoprostol, a drug that may help prevent ulcers in
people who take NSAIDs on a regular basis
• Medications that protect the tissue lining (such as
sucralfate)

14. Anti ulcer drugs- Classification
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 Gastric Acid Secretion Inhibitors
(a) H2 Antihistaminics- Ranitidine, Famotidine
(b) Proton Pump Inhibitors- Omeprazole, Lansoprazole,
Pantoprazole
(c) Anticholinergics- Pirenzepine
(d) Prostaglandin Analogues- Misoprostal
 Gastric neutralizers (Antacids)
(a) Systemic- Sodium Bicarbonate
(b) Non- Systemic-Mag. Hydroxide, Al. Hydroxide

15. Anti ulcer drugs- Classification
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 Ulcer Protectives- Sucralfate, Colloidal Bismuth Subcitrate
 Anti H. Pylori drugs- Amoxicillin, Metronidazole,
Tetracycline

16. 16

17. Gastro esophageal reflux disease
(GERD)
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18. Definition and Introduction
18
 It is chronic disease occurs due to mucosal damage
caused by reflux stomach acid coming up from the
stomach into the esophagus
 Gastroesophageal reflux disease, or GERD, is a digestive
disorder that affects the lower esophageal sphincter
(LES), the ring of muscle between the esophagus and
stomach
 Doctors believe that some people suffer
from GERD due to a condition called
hiatal hernia

19. Pathophysiology
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 GERD is caused by a failure of the cardia (part of the
stomach attached to esophagus)
 In healthy patients, the "Angle of His"—the angle at
which the esophagus enters the stomach — creates a
valve that prevents duodenal bile, enzymes, and
stomach acid from traveling back into the esophagus
where they can cause burning and inflammation of
sensitive esophageal tissue

20. Signs And Symptoms
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 Heartburn
 Regurgitation (expulsion of food particles from mouth)
 Trouble swallowing (dysphagia)
 Pain with swallowing (odynophagia)
 Excessive salivation
 Nausea
 Chest pain
 Dyspepsia
 Barret’s Esophagus

21. Most Probable Causes
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 GERD is caused by a failure of the lower esophageal sphincter.
In healthy patients, the "Angle of His"—the angle at which the
esophagus enters the stomach—creates a valve that prevents
duodenal bile, enzymes, and stomach acid from traveling back
into the esophagus where they can cause burning and
inflammation of sensitive esophageal tissue
 GERD has been linked to a variety of respiratory and laryngeal
complaints such as laryngitis, chronic cough, pulmonary
fibrosis, earache and asthma, even when not clinically apparent.
These atypical manifestations of GERD is commonly referred
to as laryngopharyngeal reflux or as extraesophageal reflux
disease (EERD)

22. Most Probable Causes
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 Factors that can contribute to GERD:
 Hiatal hernia, which increases the likelihood of GERD due
to mechanical and motility factors
 Obesity: increasing body mass index is associated with
more severe GERD. In a large series of 2000 patients with
symptomatic reflux disease, it has been shown that 13%
of changes in esophageal acid exposure is attributable to
changes in body mass index
 Zollinger-Ellison syndrome, which can be present with
increased gastric acidity due to gastrin production

23. Most Probable Causes
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 Hypercalcemia, which can increase gastrin production,
leading to increased acidity
 Scleroderma and systemic sclerosis, which can feature
esophageal dysmotility
 Visceroptosis or Glénard syndrome, in which the
stomach has sunk in the abdomen upsetting the motility
and acid secretion of the stomach
 The use of medicines such as prednisolone

24. Prevention
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Relief is often found by;
 Raising the head off the bed
 Raising the upper body with pillows
 Sleeping sitting up
• Eating a big meal causes excess stomach acid production,
and attacks can be minimized by eating small frequent
meals instead of large meals, especially for dinner.
• To minimize attacks, a sufferer may benefit from avoiding
foods that may trigger their symptoms such as restricting
the acidic fruit or juice, fatty foods, coffee, tea, chocolate,
or highly spiced foods, especially shortly before bedtime

25. 25

26. Treatment
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27. 27

28. Drug therapy-
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 Inhibitors or Neutralizers of gastric acid secretion
(a) Proton Pump Inhibitors- Omeprazole, Pantoprazole
(b) H2 Blockers- Ranitidine, Famotidine
(c) Antacids- Mg. Hydroxide, Al. Hydroxide
 Barrier Agent- Sodium Alginate
 Prokinetic Drugs (Enhance LES tone and promote
Gastric Emptying )- Cisapride, Mosapride

29. References
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 http://www.nlm.nih.gov/medlineplus/ency/article/000206.h
tm
 http://www.webmd.com/digestive-disorders/digestive-
diseases-peptic-ulcer-disease
 https://www.clinicalkey.com/topics/gastroenterology/pepti
c-ulcer-disease.html
 http://www.webmd.com/heartburn-gerd/guide/reflux-
disease-gerd-1
 K D Tripathi, Pharmacological Classification of Drugs, 4th
edition.