PEPTIC ULCER DISEASE

Dr. HUSSEIN SAAD Assistant Professor and Consultant, MRCP(UK)

FAMILY and COMMUNITY MEDICINE College of Medicine

King Saud University26/09/2016

• 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 DiseasePathogenesis :

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.

PresentationOther possible manifestations include the following:Dyspepsia, including belching, bloating, distention, and

fatty food intoleranceHeartburnChest discomfortHematemesis 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 FeaturesWarrant 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 ulcerOLD TESTAMENT

No HP No ulcer

NEW TESTAMENT

Rapid Urease TestsAre 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.

EndoscopyPerform 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/LPLT .................. .......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 sulphateB- Start her on H2 blockerC- Start her on proton pump inhibitorD- 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

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