1. Diagnosis of PUD

2. Barium Studies
Still commonly used as a first test for documenting an ulcer
80% sensitivity : single contrast barium study
90% sensitivity: double contrast barium study
Sensitivity is low for small ulcers (<0.5 cm)
Duodenal ulcers appear as a well demarcated crater most often seen at the bulb
Gastric ulcers may either be benign or malignant

3. Barium Studies
Benign gastric ulcer appears as a discrete crater with radiating mucosal folds originating from the mucosal margin
Ulcers >3 cm are more often malignant
Radiographic studies that show a gastric ulcer must be followed by endoscopy and biopsy.
Fauci, et. al. Harrison’s Principles of Internal Medicine, 17 th ed.

4. Endoscopy Most sensitive and specific
Direct visualization of the mucosa
Photographic documentation of the defect
Tissue biopsy to rule out malignancy or H. pylori.
Helpful in identifying lesions too small to detect by radiographic examination, evaluation of atypical radiographic abnormalities, or to determine if an ulcer is a source of blood loss
Fauci, et. al. Harrison’s Principles of Internal Medicine, 17 th ed.

5. Detection of H. pylori NON-INVASIVE Serology Urea Breath Test
Detection of antibodies in the serum
Urea Breath Test
Simple, rapid, early follow up
Stool antigen
Sensitive, specific, and inexpensive
Fauci, et. al. Harrison’s Principles of Internal Medicine, 17 th ed.

6. Detection of H. pylori INVASIVE (Endoscopy/Biopsy required)
Rapid urease
Simple, false negative with recent use of PPIs, antibiotics, or bismuth compounds
Histology
Provides histologic information
Culture
Time-consuming, expensive
Fauci, et. al. Harrison’s Principles of Internal Medicine, 17 th ed.

7. Treatment of PUD

8. Objectives Pain relief Healing Prevention of complications
Prevention of recurrences

9. Antacids
Rarely used as a primary therapeutic agents but are instead used for symptomatic relief
Mixture of aluminum hydroxide and magnesium hydroxide
Eg. Maalox, Mylanta
Fauci, et. al. Harrison’s Principles of Internal Medicine, 17 th ed.

10. H2 Receptor Antagonists
Inhibit basal and stimulated acid secretion
Often used for treatment of active ulcers (4-6 weeks) in combination with an antibiotic directed at eradicating H. pylori.
Eg. Cimetidine, Ranitidine, Famotidine, Nizatidine
Fauci, et. al. Harrison’s Principles of Internal Medicine, 17 th ed.

11. Proton Pump Inhibitors
Substituted benzimidazole derivatives that covalently bind and irreversibly inhibit H+K+-ATPase
Eg. Omeprazole, Esomeprazole, Lansoprazole, Rabeprazole, Pantoprazole
Fauci, et. al. Harrison’s Principles of Internal Medicine, 17 th ed.

12. Cytoprotective Agents
Sucralfate
Insoluble in water
Viscous paste within the stomach and duodenum, binding primarily to sites of active ulceration
Bismuth-containing compounds
Ulcer coating; prevention of further pepsin/HCl-induced damage; binding of pepsin; and stimulation of PGs, bicarbonate, and mucous secretion
Prostaglandin Analogues
Enhancement of mucosal defense and repair
Eg. Misoprostol
Fauci, et. al. Harrison’s Principles of Internal Medicine, 17 th ed.

13. THERAPY FOR H. pylori Eradication of H. pylori is the primary goal
DRUG
DOSE
TRIPLE THERAPY
Bismuth subsalicylate plus Metronidazole plus
Tetracycline
Ranitidine bismuth citrate plus Tetracycline plus
Clarithromycin or Metronidazole
Omeprazole (lansoprazole) plus Clarithromycin plus
Metronidazole or
Amoxicillin
2 tabs qid
250 mg qid
500 mg qid
400 mg bid
500 mg bid
20 mg bid (30 mg bid)
250 or 500 mg bid
1 g bid

14. Bismuth subsalicylate Metronidazole Tetracycline 20 mg (30 mg) daily
DRUG
DOSE
QUADRUPLE THERAPY
Omeprazole
Bismuth subsalicylate
Metronidazole
Tetracycline
20 mg (30 mg) daily
2 tablets qid
250 mg qid
500 mg qid
Fauci, et. al. Harrison’s Principles of Internal Medicine, 17 th ed.