1. Peptic Ulcer Disease Dr. Wael H. Mansy, MD Assistant Professor
College of Pharmacy
King Saud University

2. Peptic Ulcer Disease (PUD)
Objectives:
Define the following terms: peptic ulcer, gastric ulcer,
Discuss the different etiologic factors of PUD
List the role of H.pylori as the main cause of PUD.
Describe the role of each of these specific cells in the immune response.
Discuss the different diagnostic methods of PUD
Discuss the complications of PUD
Discuss the treatment of PUD

3. Peptic Ulcer Disease (PUD)
Definition
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%)

4. Normal
Esophagus & Stomach

5. Peptic Ulcer Disease Pathogenesis :
Protective factors vs. hostile factors

6. Etiology of PUD A) Normal B) Increased Attack *Hyperacidity
*Pepsin.
*NSAIDs.
C) Weak defense *Helicobacter pylori *Stress, drugs, smoking

7. Peptic ulcer disease

8. Peptic Ulcer Disease
Pathogenesis :

9. Peptic Ulcer Disease Causes:
The causes of peptic ulcer disease include the following:
Infection with the bacteria Helicobacter pylori occurs in 80 to 95% of patients with peptic ulcer disease. H. pylori infection impairs the protective mechanisms of the G.I. tract against low pH and digestive enzymes and leads to ulceration of the mucosa.
Stress — Emotional, trauma, surgical.
Injury or death of mucus-producing cells.
Excess acid production in the stomach. The hormone gastrin stimulates the production of acid in the stomach; therefore, any factors that increase gastrin production will in turn increase the production of stomach acid.
Drugs: Chronic use of aspirins and NSAIDs, or Corticosteroids

10. ETIOLOGIC FACTORS OF PUD

11. Helicobacter pylori: No acid No ulcer No HP No ulcer
Most common infection in the world (20%)
10% of men, 4% women develop PUD
Positive in % of PUD patients.
H.pylori related disorders:
Chronic gastritis – 90%
Peptic ulcer disease – %
Gastric carcinoma – 70%
Gastric lymphoma
Reflux Oesophagitis.
Non ulcer dyspepsia
No acid
No ulcer
OLD TESTAMENT
No HP
No ulcer
NEW TESTAMENT

12. Helicobacter pylori: Gram negative, Spiral bacilli Spirochetes
Do not invade cells – only mucous
Breakdown urea - ammonia
Break down mucosal defense
Chronic Superficial inflammation

13. Duodenal Ulcer Vs. Gastric Ulcer
duodenal sites are 4x as common as gastric sites
most common in middle age with peak years
Male to female ratio—4:1
Genetic link: 3x more common in 1st degree relatives
more common with blood group O
associated with increased serum pepsinogen
H. pylori infection common,up to 95%
smoking is twice as common
common in late middle age.
incidence increases with age.
Male to female ratio—2:1
More common with bl. group A
Use of NSAIDs: associated with a three- to four-fold increase in risk of gastric ulcer
Less related to H. pylori than duodenal ulcers : about 80%
% of patients with a gastric ulcer have a concomitant duodenal ulcer

14. Peptic Ulcer Disease Manifestations:
Manifestations of peptic ulcer disease:
• Episodes of remission and exacerbation
• Pain that for duodenal ulcers is often relieved by eating or antacids
• G.I. bleeding and possible hemorrhage (20 to 25% of patients)
• Perforation of ulcers with significant mortality
• Obstruction of G.I. tract

15. PUD - Diagnosis Endoscopy Barium meal – contrast x-ray
Biopsy – bacteria & malignancy
H.Pylori:
Endoscopy cytology
Biopsy – Special stains
Culture - difficult
Urease Breath test.

16. Urease Breath Test.

17. PUD – Complications Bleeding – Chronic, Acute, Massive
Fibrosis, Stricture obstruction – pyloric stenosis.
Perforation – Peritonitis- emergency.
Gastric carcinoma. (not duodenal carcinoma)

18. Non-pharmacological Treatment of Peptic ulcer
1-Avoid spicy food.
2-Avoid xanthin containing beverges.
3-Avoid Alcohol.
4-Avoid Smoking.
5-Avoid heavy meals.
6-Encourage small frequent low caloric meals.
7-Avoid ulcerating drugs e.g. NSAIDs, corticosteroids, xanthines and parasympathomimetics

19. PUD –Treatment
Triple therapy for 14 days is considered the ttt of choice.
Proton Pump Inhibitor + clarithromycin and amoxicillin
Omeprazole (Prilosec): 20 mg PO bid for 14 d or Lansoprazole (Prevacid): 30 mg PO bid for 14 d or Rabeprazole (Aciphex): 20 mg PO bid for 14 d or Esomeprazole (Nexium): 40 mg PO qd for 14 d plus Clarithromycin (Biaxin): 500 mg PO bid for 14 and Amoxicillin (Amoxil): 1 g PO bid for 14 d
Can substitute Flagyl 500 mg PO bid for 14 d if allergic to Penicillin.
In the setting of an active ulcer, continue on proton pump inhibitor therapy for additional 2 weeks.
Goal: complete elimination of H. Pylori. Once achieved reinfection rates are low.

20. Reference list
Fantry, G. T. (2005, May 6). Peptic Ulcer Disease. Retrieved September 4th, 2006, from
General Practice Notebook (2006). Peptic Ulcer. Retrieved September 10th, 2006, from
Microbe Wiki (2006, August 16). Heliobacter. Retrieved September 10th, 2006, from
Moore, R. A. (1995). Helicobacter pylori and peptic ulcer: A systematic review of effectiveness and an overview of the economic benefits of implementing what is known to be effective. Oxford: Cortecs Limited and Health Technology Evaluation Association.
Pounder, R. (1994). Peptic ulceration. Medicine International, 22:6,
Rodney, W.M. (2005, Summer). H. Pylori eradication options for peptic ulcer. Nurse Practitioners Prescribing Reference,12(2), 150.
Uphold, C. R. & Graham, M. V. (2003). Clinical Guidelines in Family Practice (4th ed.). Gainesville, FL: Barmarrae Books, Inc.