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PEPTIC ULCER
DISEASE
Dr. HUSSEIN SAAD
Assistant Professor and Consultant, MRCP(UK)
FAMILY and COMMUNITY MEDICINE
College of Medicine
King Saud University
26/09/2016
• Aetiology
• Presentation
• Approash:
 Diagnosis
 H pylori
 Management
Case
• A 36-year-old man, smoker, presents with 2
months H/O epigastric pain mainly post meals.
He sometimes awake by night because of
burning pain to which he used to drink milk to
relieve the pain.
• No vomiting
• He has no H/o any chronic illnesses
• No H/o of drugs
Peptic ulcer
 Refers 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 malignant
 Duodenal ulcer : most often seen in first portion of duodenum (>95%)
Peptic Ulcer Disease (PUD)
Definition
Peptic ulcer disease
Peptic Ulcer Disease
Pathogenesis :
Aetiology
•H pylori infection
•Drugs like NSAIDs, Aspirin or
Corticosteroids
•Smoking
•Stress like trauma, surgery
•Excess gastrin secretion
ETIOLOGIC FACTORS OF PUD
Presentation
• Gastric and duodenal ulcers usually cannot be
differentiated based on history alone.
• Epigastric pain is the most common symptom.
• It is characterized by a burning sensation and occurs
after meals—classically, shortly after meals with
gastric ulcer and 2-3 hours afterward with duodenal
ulcer.
Presentation
• Food or antacids relieve the pain of duodenal ulcers
but provide minimal relief of gastric ulcer pain.
• Duodenal ulcer pain often awakens the patient at
night.
• About 50-80% of patients with duodenal ulcers
experience nightly pain, as opposed to only 30-40% of
patients with gastric ulcers and 20-40% of patients
with nonulcer dyspepsia (NUD).
Case
• A 36-year-old man, smoker, presents with 2
months H/O epigastric pain mainly post meals.
He sometimes awake by night because of
burning pain to which he used to drink milk to
relieve the pain.
• No vomiting
• He has no H/o any chronic illnesses
• No H/o of drugs
Presentation
• Pain with radiation to the back is suggestive of a
posterior penetrating gastric ulcer complicated by
pancreatitis.
• Patients who develop gastric outlet obstruction as a
result of a chronic, untreated duodenal ulcer usually
report a history of fullness and bloating associated
with nausea and emesis that occurs several hours
after food intake.
Presentation
Other possible manifestations include the following:
Dyspepsia, including belching, bloating, distention, and
fatty food intolerance
Heartburn
Chest discomfort
Hematemesis or melena resulting from gastrointestinal
bleeding. Melena may be intermittent over several days or
multiple episodes in a single day.
Symptoms consistent with IDA (eg, fatigue, dyspnea).
NSAID-induced gastritis or ulcers may be silent,
especially in elderly patients.
Alarm Features
Warrant prompt gastroenterology referral:
• Bleeding or anemia
• Early satiety
• Unexplained weight loss
• Progressive dysphagia or odynophagia
• Recurrent vomiting
• Family history of GI cancer
Serum Gastrin Level
• A fasting serum gastrin level should be obtained in certain
cases to screen for Zollinger-Ellison syndrome.
• Patients with multiple ulcers
• Strong family history of PUD
• Peptic ulcer associated with diarrhea, steatorrhea, or
weight loss
• Peptic ulcer not associated with H pylori infection or
NSAID use
• Peptic ulcer associated with hypercalcemia or renal stones
• Ulcer refractory to medical therapy
• Ulcer recurring after surgery
•
Differential Diagnoses
• Acute Cholangitis
• Acute Coronary Syndrome
• Acute Gastritis
• Cholecystitis and Biliary Colic
• Chronic Gastritis
• Diverticulitis
• Esophagitis
• Gallstones (Cholelithiasis)
• Gastroesophageal Reflux Disease
• Inflammatory Bowel Disease
• Viral Hepatitis
Types of Ulcer
• Benign ulcers tend to have a smooth, regular, rounded
edge with a flat smooth base and surrounding mucosa
that shows radiating folds.
• Malignant ulcers usually have irregular heaped-up or
overhanging margins. The ulcerated mass often protrudes
into the lumen, and the folds surrounding the ulcer crater
are often nodular and irregular.
Benign Ulcers
Malignant Ulcer
Helicobacter pylori
 Gram negative, Spiral bacilli
 Spirochetes
 Do not invade cells – only mucous
 Breakdown urea - ammonia
 Break down mucosal defense
 Chronic Superficial inflammation
H pylori Testing
• Testing for H pylori infection is essential in all
patients with peptic ulcers.
No acid
No ulcer
OLD TESTAMENT
No HP No ulcer
NEW TESTAMENT
Rapid Urease Tests
Are considered the endoscopic diagnostic test of choice.
The presence of H pylori in gastric mucosal biopsy
specimens is detected by testing for the bacterial product
urease.
The kit contains a combination of a urea substrate and a pH
sensitive indicator. One or more gastric biopsy specimens
are placed in the rapid urease test kit. If H pylori is present,
bacterial urease converts urea to ammonia, which changes
the pH, resulting in a color change.
Urease Test
Histopathology
• Often considered the criterion standard to establish a
diagnosis of H pylori infection , if the rapid urease test
result is negative and a high suspicion for H pylori persists
(presence of a duodenal ulcer).
Urea Breath Tests (13C and14C)
• Detect active H pylori infection by testing for the
enzymatic activity of bacterial urease.
• In the presence of urease produced by H pylori, labeled
carbon dioxide (heavy isotope, carbon-13, or radioactive
isotope, carbon-14) is produced in the stomach, absorbed
into the bloodstream, diffused into the lungs, and exhaled.
Fecal Antigen Testing
• Identifies active H pylori infection by detecting the
presence of H pylori antigens in stools.
• This test is more accurate than antibody testing and is
less expensive than urea breath tests.
Antibodies
• (Immunoglobulin G [IgG]) to H pylori can be measured in
serum, plasma, or whole blood.
• Not effective in follow up after eradication.
Approach Considerations
Treatment of peptic ulcers varies depending on:
• The etiology and clinical presentation.
• Stable patient with dyspepsia
• An unstable patient with Alarm Features
Treatment Options
• Empiric anti-secretory therapy,
• Empiric triple therapy for H pylori infection,
• Endoscopy followed by appropriate therapy based on
findings,
• H pylori serology followed by triple therapy for patients
who are infected.
• Breath testing for active H pylori infection may be used.
• Endoscopy is required to document healing of gastric
ulcers and to rule out gastric cancer.
• This usually is performed 6-8 weeks after the initial
diagnosis of PUD.
Endoscopy
Perform endoscopy early in:
• Patients older than 45-50 years
• Patients with alarm symptoms, such as dysphagia,
recurrent vomiting, weight loss, or bleeding.
Case
• A 42-year-old man came to follow the result of endoscopy
done few days ago.
Endoscopy Result:
• Antral erosions
• Duodenal erosions
• Urease test is positive for H pylori
• How are you going to manage him?
Acid Suppression
Two classes of acid-suppressing medications currently in
use are:
• Histamine-2 receptor antagonists (H2RAs)
• Proton pump inhibitors (PPIs).
• Both classes are available in intravenous and oral
preparations.
• Examples of H2RAs include ranitidine, cimetidine, ....
Examples of PPIs include omeprazole, pantoprazole,
lansoprazole, …..
Proton Pump Inhibitors (PPIs)
• Good safety profile
• Adverse effects, especially with long-term and/or high-
dose therapy, such as:
• Clostridium difficile infection,
• community-acquired pneumonia,
• hip fracture,
• and vitamin B12 deficiency.
• PPIs impair gastric secretion of acid; thus, absorption of
any medication that depends on gastric acidity, such as
iron, is impaired with long-term PPI therapy.
Triple-therapy regimens for H pylori
A 14-day regimen as shown below:
• Omeprazole: 20 mg PO bid
• or
• Esomeprazole (Nexium): 40 mg PO qd
• Plus
• Clarithromycin: 500 mg PO bid
• and
• Amoxicillin: 1 g PO bid
Alternative triple-therapy regimens
•The alternative triple therapies, also administered for 14 days, are as follows:
• Omeprazole : 20 mg PO bid
• Or
• Esomeprazole (Nexium): 40 mg PO qd
• Plus
• Clarithromycin: 500 mg PO bid
• and
• Metronidazole (Flagyl): 500 mg PO bid
A 62-year-old lady, known case of IHD presents with one week
H/O black stools which is documented to be melena on PR.
She was pale and abdomen is soft.
Investigations revealed:
HGB ....................... 96 120 – 160 g/L
PLT .................. .......260 140 – 450 x10.e9/L
What is the most common cause could be responsible for this condition?
Aspirin
The most appropriate next step to do is:
A- Start her on ferrous sulphate
B- Start her on H2 blocker
C- Start her on proton pump inhibitor
D- Refer her for gastroscopy
Answer D
Medical Management of NSAID Ulcers
• According to the ACG guideline, all patients who are
beginning long-term NSAID therapy should first be tested
for H pylori.
• NSAIDs should be immediately discontinued in patients
with positive H pylori test results if clinically feasible and
given eradication therapy.
• For patients who must continue with their NSAIDs, PPI
maintenance is recommended to prevent recurrences even
after eradication of H pylori.
• If NSAIDs must be continued, changing to a COX-2
selective inhibitor is an option.
Prophylactic or Preventive Therapy
• Patients with NSAID-induced ulcers who require chronic,
daily NSAID therapy
• Patients older than 60 years
• Patients with a history of PUD or a complication such as
gastrointestinal bleeding
• Patients taking concomitant steroids or anticoagulants or
patients with significant comorbid medical illnesses
Reference
• American College of Gastroenterology
2012
‫الــوالــديــن‬ ‫بــر‬
THANK
YOU

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B1 git med1 peptic ulcer disease

  • 1. PEPTIC ULCER DISEASE Dr. HUSSEIN SAAD Assistant Professor and Consultant, MRCP(UK) FAMILY and COMMUNITY MEDICINE College of Medicine King Saud University 26/09/2016
  • 2. • Aetiology • Presentation • Approash:  Diagnosis  H pylori  Management
  • 3. Case • A 36-year-old man, smoker, presents with 2 months H/O epigastric pain mainly post meals. He sometimes awake by night because of burning pain to which he used to drink milk to relieve the pain. • No vomiting • He has no H/o any chronic illnesses • No H/o of drugs
  • 4. Peptic ulcer  Refers 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 malignant  Duodenal ulcer : most often seen in first portion of duodenum (>95%) Peptic Ulcer Disease (PUD) Definition
  • 7. Aetiology •H pylori infection •Drugs like NSAIDs, Aspirin or Corticosteroids •Smoking •Stress like trauma, surgery •Excess gastrin secretion
  • 9. Presentation • Gastric and duodenal ulcers usually cannot be differentiated based on history alone. • Epigastric pain is the most common symptom. • It is characterized by a burning sensation and occurs after meals—classically, shortly after meals with gastric ulcer and 2-3 hours afterward with duodenal ulcer.
  • 10. Presentation • Food or antacids relieve the pain of duodenal ulcers but provide minimal relief of gastric ulcer pain. • Duodenal ulcer pain often awakens the patient at night. • About 50-80% of patients with duodenal ulcers experience nightly pain, as opposed to only 30-40% of patients with gastric ulcers and 20-40% of patients with nonulcer dyspepsia (NUD).
  • 11. Case • A 36-year-old man, smoker, presents with 2 months H/O epigastric pain mainly post meals. He sometimes awake by night because of burning pain to which he used to drink milk to relieve the pain. • No vomiting • He has no H/o any chronic illnesses • No H/o of drugs
  • 12. Presentation • Pain with radiation to the back is suggestive of a posterior penetrating gastric ulcer complicated by pancreatitis. • Patients who develop gastric outlet obstruction as a result of a chronic, untreated duodenal ulcer usually report a history of fullness and bloating associated with nausea and emesis that occurs several hours after food intake.
  • 13. Presentation Other possible manifestations include the following: Dyspepsia, including belching, bloating, distention, and fatty food intolerance Heartburn Chest discomfort Hematemesis or melena resulting from gastrointestinal bleeding. Melena may be intermittent over several days or multiple episodes in a single day. Symptoms consistent with IDA (eg, fatigue, dyspnea). NSAID-induced gastritis or ulcers may be silent, especially in elderly patients.
  • 14. Alarm Features Warrant prompt gastroenterology referral: • Bleeding or anemia • Early satiety • Unexplained weight loss • Progressive dysphagia or odynophagia • Recurrent vomiting • Family history of GI cancer
  • 15. Serum Gastrin Level • A fasting serum gastrin level should be obtained in certain cases to screen for Zollinger-Ellison syndrome. • Patients with multiple ulcers • Strong family history of PUD • Peptic ulcer associated with diarrhea, steatorrhea, or weight loss • Peptic ulcer not associated with H pylori infection or NSAID use • Peptic ulcer associated with hypercalcemia or renal stones • Ulcer refractory to medical therapy • Ulcer recurring after surgery •
  • 16. Differential Diagnoses • Acute Cholangitis • Acute Coronary Syndrome • Acute Gastritis • Cholecystitis and Biliary Colic • Chronic Gastritis • Diverticulitis • Esophagitis • Gallstones (Cholelithiasis) • Gastroesophageal Reflux Disease • Inflammatory Bowel Disease • Viral Hepatitis
  • 17. Types of Ulcer • Benign ulcers tend to have a smooth, regular, rounded edge with a flat smooth base and surrounding mucosa that shows radiating folds. • Malignant ulcers usually have irregular heaped-up or overhanging margins. The ulcerated mass often protrudes into the lumen, and the folds surrounding the ulcer crater are often nodular and irregular.
  • 20. Helicobacter pylori  Gram negative, Spiral bacilli  Spirochetes  Do not invade cells – only mucous  Breakdown urea - ammonia  Break down mucosal defense  Chronic Superficial inflammation
  • 21. H pylori Testing • Testing for H pylori infection is essential in all patients with peptic ulcers. No acid No ulcer OLD TESTAMENT No HP No ulcer NEW TESTAMENT
  • 22. Rapid Urease Tests Are considered the endoscopic diagnostic test of choice. The presence of H pylori in gastric mucosal biopsy specimens is detected by testing for the bacterial product urease. The kit contains a combination of a urea substrate and a pH sensitive indicator. One or more gastric biopsy specimens are placed in the rapid urease test kit. If H pylori is present, bacterial urease converts urea to ammonia, which changes the pH, resulting in a color change.
  • 24. Histopathology • Often considered the criterion standard to establish a diagnosis of H pylori infection , if the rapid urease test result is negative and a high suspicion for H pylori persists (presence of a duodenal ulcer).
  • 25. Urea Breath Tests (13C and14C) • Detect active H pylori infection by testing for the enzymatic activity of bacterial urease. • In the presence of urease produced by H pylori, labeled carbon dioxide (heavy isotope, carbon-13, or radioactive isotope, carbon-14) is produced in the stomach, absorbed into the bloodstream, diffused into the lungs, and exhaled.
  • 26. Fecal Antigen Testing • Identifies active H pylori infection by detecting the presence of H pylori antigens in stools. • This test is more accurate than antibody testing and is less expensive than urea breath tests.
  • 27. Antibodies • (Immunoglobulin G [IgG]) to H pylori can be measured in serum, plasma, or whole blood. • Not effective in follow up after eradication.
  • 28. Approach Considerations Treatment of peptic ulcers varies depending on: • The etiology and clinical presentation. • Stable patient with dyspepsia • An unstable patient with Alarm Features
  • 29. Treatment Options • Empiric anti-secretory therapy, • Empiric triple therapy for H pylori infection, • Endoscopy followed by appropriate therapy based on findings, • H pylori serology followed by triple therapy for patients who are infected. • Breath testing for active H pylori infection may be used. • Endoscopy is required to document healing of gastric ulcers and to rule out gastric cancer. • This usually is performed 6-8 weeks after the initial diagnosis of PUD.
  • 30. Endoscopy Perform endoscopy early in: • Patients older than 45-50 years • Patients with alarm symptoms, such as dysphagia, recurrent vomiting, weight loss, or bleeding.
  • 31. Case • A 42-year-old man came to follow the result of endoscopy done few days ago. Endoscopy Result: • Antral erosions • Duodenal erosions • Urease test is positive for H pylori • How are you going to manage him?
  • 32. Acid Suppression Two classes of acid-suppressing medications currently in use are: • Histamine-2 receptor antagonists (H2RAs) • Proton pump inhibitors (PPIs). • Both classes are available in intravenous and oral preparations. • Examples of H2RAs include ranitidine, cimetidine, .... Examples of PPIs include omeprazole, pantoprazole, lansoprazole, …..
  • 33. Proton Pump Inhibitors (PPIs) • Good safety profile • Adverse effects, especially with long-term and/or high- dose therapy, such as: • Clostridium difficile infection, • community-acquired pneumonia, • hip fracture, • and vitamin B12 deficiency. • PPIs impair gastric secretion of acid; thus, absorption of any medication that depends on gastric acidity, such as iron, is impaired with long-term PPI therapy.
  • 34. Triple-therapy regimens for H pylori A 14-day regimen as shown below: • Omeprazole: 20 mg PO bid • or • Esomeprazole (Nexium): 40 mg PO qd • Plus • Clarithromycin: 500 mg PO bid • and • Amoxicillin: 1 g PO bid Alternative triple-therapy regimens •The alternative triple therapies, also administered for 14 days, are as follows: • Omeprazole : 20 mg PO bid • Or • Esomeprazole (Nexium): 40 mg PO qd • Plus • Clarithromycin: 500 mg PO bid • and • Metronidazole (Flagyl): 500 mg PO bid
  • 35. A 62-year-old lady, known case of IHD presents with one week H/O black stools which is documented to be melena on PR. She was pale and abdomen is soft. Investigations revealed: HGB ....................... 96 120 – 160 g/L PLT .................. .......260 140 – 450 x10.e9/L What is the most common cause could be responsible for this condition? Aspirin The most appropriate next step to do is: A- Start her on ferrous sulphate B- Start her on H2 blocker C- Start her on proton pump inhibitor D- Refer her for gastroscopy Answer D
  • 36. Medical Management of NSAID Ulcers • According to the ACG guideline, all patients who are beginning long-term NSAID therapy should first be tested for H pylori. • NSAIDs should be immediately discontinued in patients with positive H pylori test results if clinically feasible and given eradication therapy. • For patients who must continue with their NSAIDs, PPI maintenance is recommended to prevent recurrences even after eradication of H pylori. • If NSAIDs must be continued, changing to a COX-2 selective inhibitor is an option.
  • 37. Prophylactic or Preventive Therapy • Patients with NSAID-induced ulcers who require chronic, daily NSAID therapy • Patients older than 60 years • Patients with a history of PUD or a complication such as gastrointestinal bleeding • Patients taking concomitant steroids or anticoagulants or patients with significant comorbid medical illnesses
  • 38. Reference • American College of Gastroenterology 2012