RISK FACTORS
. Strongly associated: Drugs (e.g., NSAID use), family
history of ulcer, Zollinger-Ellison syndrome (gastrinoma),
cigarettes (>1/2 pack/day)
. Possibly associated: Corticosteroids (high dose and/or
prolonged therapy); blood group O;
RISK FACTORS
. Strongly associated: Drugs (e.g., NSAID use), family history of ulcer, Zollinger-Ellison syndrome (gastrinoma),
cigarettes (>1/2 pack/day)
. Possibly associated: Corticosteroids (high dose and/or prolonged therapy); blood group O; HLA-B12, B5,
Bw35 phenotypes; stress; lower socioeconomic status; manual labor
. Poorly or not associated: Dietary spices, alcohol, caffeine, acetaminophen
. Lifetime risk for PUD in H. pylori infected individuals is 15%
. Annual risk of DU developing in H. pylori - positive individual .1%
Medical Care:
" Given current understanding of the pathogenesis of PUD, the majority of patients with PUD are treated successfully medically with cure of H pylori infection and/or avoidance of NSAIDs, along with appropriate use of antisecretory therapy.
" A number of treatment options exist for patients presenting with symptoms suggestive of PUD or ulcerlike dyspepsia, including empiric antisecretory therapy, empiric triple therapy for H pylori infection, endoscopy followed by appropriate therapy based on findings, and H pylori serology followed by triple therapy for infected patients. Breath testing for active H pylori infection may be used.
" Computer models have suggested that obtaining an H pylori serology followed by triple therapy for those infected is the most cost-effective approach; however, no direct evidence from clinical trials confirms this.
" Perform endoscopy early in patients older than 45-50 years and in patients with associated so-called alarm symptoms, such as dysphagia, recurrent vomiting, weight loss, or with signs of bleeding.
Surgical Care: With the success of medical therapy, surgery has a very limited role in the management of PUD.
" Potential indications for surgery include refractory disease, and complications of PUD include the following:
o Refractory, symptomatic peptic ulcers, though rare with the cure of H pylori and the appropriate use of antisecretory therapy, are a potential complication of PUD.
o Perforation usually is managed emergently with surgical repair. However, this is not mandatory for all patients.
o Obstruction can complicate PUD, particularly if PUD is refractory to aggressive antisecretory therapy, H pylori eradication, or avoidance of NSAIDs. Obstruction may persist or recur despite endoscopic balloon dilation.
o Penetration, particularly if not walled-off or if a gastrocolic fistula develops, is a potential complication of PUD.
o Bleeding can complicate PUD, particularly in patients with massive hemorrhage and hemodynamic instability, recurrent bleeding on medical therapy, and failure of therapeutic endoscopy to control bleeding.
" The appropriate surgical procedure depends on the location and nature of the ulcer.
o Many authorities recommend simple oversewing of the ulcer with treatment of underlying H pylori infection or cessation of NSAIDs for bleeding PUD.
o Additional surgical options for refractory or complicated PUD include vagotomy and pyloroplasty, vagotomy and antrectomy with gastroduodenal reconstruction (Billroth I) or gastrojejunal reconstruction (Billroth II), or a highly selective vagotomy.
Diet: No special diet is required.
DRUG TREATMENT : Triple therapies for H pylori infection -- Triple therapy for 14 days is considered the treatment of choice for H pylori infection. Two forms of triple therapy are available, including proton pump inhibitor-based triple therapy and bismuth-based triple therapy. Proton pump inhibitor-based triple therapy consists of a proton pump inhibitor and 2 antibiotics, each bid for 2 weeks. In the setting of an active ulcer, continue qd proton pump inhibitor therapy for additional 2 weeks. Bismuth-based triple therapy consists of bismuth subsalicylate and 2 antibiotics, each qid for 2 weeks. In the setting of an active ulcer, addition of an antisecretory agent, such as an H2-receptor antagonist, is recommended to optimize ulcer healing.
1. PROTON PUMP INHIBITORS ( OMEPRAZOLE, PANTOPRAZOLE, RABEPRAZOLE, LANSOPRAZOLE, ESOMEPRAZOLE ) BD + CLARITHROMYCIN ( 500 MG BD ) + AMOXICILLIN 1 GM BD FOR 14 DAYS
- IN PENICILLIN ALLERGY :
PROTON PUMP INHIBITORS ( OMEPRAZOLE, PANTOPRAZOLE, RABEPRAZOLE, LANSOPRAZOLE, ESOMEPRAZOLE ) BD + CLARITHROMYCIN ( 500 MG BD ) + METRONIDAZOLE 500 MG BD FOR 14 DAYS
2. CYTOPROTECTANTS :
- MISOPROSTOL
3. H-2 RECEPTOR BLOCKERS
- CIMETIDINE
- RANITIDINE
- FAMOTIDINE
- NIZATIDINE
PATIENT MONITORING
. Eradication of H. pylori : Expected in >90% (with 2 antibiotic regimen)
. Confirm eradication by CLOtest biopsy, histology, urea breath test, or stool antigen (has high predictive
value on day 7 after treatment) in patients who remain symptomatic or relapse
. Blood antibody less useful in the immediate posttreatment period
. Treatment failure: use different antimicrobial regimen or test for sensitivity
. Acute DU: monitor clinical response. No need to repeat endoscopy or x-ray exam to document healing unless recurrence or complication suspected.
. Acute GU: confi rm healing (endoscopy after 6-12 weeks for cytology and biopsy of poorly or unhealed
ulcer to rule out malignancy)
. Symptomatic response to therapy does not preclude malignancy
PREVENTION/AVOIDANCE
. Eradication of HP: recurrence < 10% in the fi rst year, off of all therapies
. Maintenance therapy (using proton pump inhibitor or H2 blocker) suppresses ulcer relapse indefinitely while
treatment is continued - however, relapses occur in most patients who remain HP positive off therapy
. Bleeding ulcers require continued maintenance therapy (e.g., H2 blocker or PPI if H. pylori not eradicated )
. NSAID-related ulcers: avoid salicylates and NSAIDs. If NSAIDs needed, add misoprostol (Cytotec) or proton
pump inhibitor.
. To reduce ulcer risk, eradicate H. pylori prior to start of NSAIDs
. Selective COX-2 NSAIDs (e.g., celecoxib) produce significantly fewer GI ulcers; consider for use in patients
at risk for ulceration
. Eradication of H. pylori proven to reduce risk of gastric cancer
POSSIBLE COMPLICATIONS
. Hemorrhage in up to 25% of cases (initial presentation in 10%)
. Perforation occurs in < 5%, usually related to NSAID use