1. Gastric and Duodenal Ulcer

2. 2 What is a Peptic Ulcer? It is a hole that forms in the mucosal wall of the stomach, in the pylorus (opening between stomach and duodenum), in the duodenum (first part of small intestine), or in the esophagus. It is frequently referred to as a gastric, duodenal, or esophageal ulcer, depending on its location, or as peptic ulcer disease. It is more likely to be in the duodenum than in the stomach. Chronic gastric ulcers tend to occur in the lesser curvature of the stomach, near the pylorus.

3. 3 Risk Factors For Peptic Ulcers Infection with bacteria "Helicobacter pyloricus" (H. pylori). Gastritis, alcohol, smoking, use of NSAIDs, and stress. Familial tendency may be a significant predisposing factor. People with blood type O are more susceptible to peptic ulcers than are those with other types. Rarely, ulcers are caused by excessive amounts of the hormone gastrin, produced by tumors. This Zollinger-Ellison syndrome (ZES) consists of severe peptic ulcers, extreme gastric hyperacidity, and gastrin-secreting benign or malignant tumors of the pancreas.

4. 4 Clinical Manifestations Many people have symptomless ulcers, and in 20% to 30% perforation or hemorrhage may occur without any preceding manifestations. Dull, gnawing [persistent & troubling] pain or a burning sensation in the midepigastrium. The pain may occur when the increased acid content of the stomach and duodenum erodes the lesion and stimulates the exposed nerve endings. Pain is usually relieved by eating, or by taking alkali. Sharply localized tenderness can be elicited by applying gentle pressure to the epigastrium at or slightly to the right of the midline.

5. 5 Pyrosis (heartburn), vomiting, and bleeding. Pyrosis is a burning sensation in the esophagus and stomach that moves up to the mouth. Heartburn is often accompanied by sour eructation, which is common when the patient’s stomach is empty. Fifteen percent of patients with gastric ulcers experience bleeding, as evidenced by the passage of tarry stools.

6. 6 Assessment and Diagnostic Findings A physical examination may reveal pain, epigastric tenderness, or abdominal distention. Pain that is relieved by ingesting food or antacids and absence of pain on arising are also highly suggestive of an ulcer. Endoscopy is useful procedure because it allows direct visualization of inflammatory changes, ulcers, and lesions. A biopsy of the gastric mucosa and of any suspicious lesions can be obtained. Biopsy and histology with culture can determine H. Pylori. Stools may be tested for occult blood (OB).

7. 7 Medical Management The purpose of medical management of peptic ulcer is to eradicate H. pylori and to manage gastric acidity. This is achieved through pharmacologic therapy, lifestyle changes, and surgical intervention. These are described next.

8. 8 Pharmacologic Therapy A combination of antibiotics (clarithromycin & amoxicillin), proton pump inhibitors (omeprazole), and bismuth salts (bismuth subsalicylate) that suppresses or eradicates H. pylori; Antibiotics assist in eradicating H. pylori bacteria. Histamine 2 (H2) receptor antagonists (Ranitidine) and proton pump inhibitors are used to treat NSAID-induced and other ulcers not associated with H. pylori ulcers. Bismuth salts suppress H. pylori bacteria in the gastric mucosa and assists with healing of mucosal lesions. H2 receptor antagonists inhibit acid secretion by blocking the action of the histamine on the histamine receptors in the stomach.

9. 9 Life Style Changes Stress reduction and rest –The patient may need avoid situations that are stressful or exhausting. A rushed lifestyle and an irregular schedule may aggravate symptoms and interfere with regular meals taken in relaxed settings and with the regular administration of medications. –The patient may benefit from regular rest periods during the day, at least during the acute phase of the disease. Smoking cessation –Smoking decreases the secretion of bicarbonate from the pancreas into the duodenum, resulting in increasing its acidity. –Smoking may significantly inhibit ulcer repair. Therefore, the patient is strongly encouraged to stop smoking.

10. 10 Dietary modification –Dietary modification is required to avoid oversecretion of acid and hypermotility in the GI tract. Therefore, avoiding extremes of temperature and overstimulation from consumption of meat extracts, alcohol, coffee and other caffeinated beverages, and diets rich in milk and cream. –In addition, an effort is made to neutralize acid by eating three regular meals a day. Surgery –Surgery is usually recommended for patients with intractable ulcers (those that fail to heal after 12 to 16 weeks of medical treatment), life-threatening hemorrhage, perforation, or obstruction.

11. Standard doses of PPIs: Esomeprazole 40 mg Pantoprazole 40mg Loseprazole 30mg Omeprazole 20mg 11

12. 12 H. Pylori eradication the first trial in Poland 10 – 14 days therapy: 2 standard doses of PPI e.g. 2 x 40mg pantoprazole + 2 antibiotics from: Amoxicilin 2 x 1000mg Metronidazole 2 x 500mg Clarithromycin 2 x 500mg 12