pepic ulcer
TRANSCRIPT
TREATMENT OF PEPTIC ULCER
By :DR. NAWRAS Maher & DR. Batool
Obaid
DEFINITION & PATHOPHYSIOLOGY
Definition : ulcer is a break in the mucosal surface >5 mm in size, with depth to the submucosa
penetrating the muscularis mucosa
Pathophysiology of peptic ulcer disease P.U is the end result of an imbalance between
aggressive and defensive factors in the Gastroduodenal mucosa
Factors Affecting The Incidence of Peptic Ulcer Disorder
• H. pylori infection: ( 75% of G.U & 90% of D.U) • Drugs: NSAIDs, Corticosteroids & Reserpine• Cigarette smoking • Alcohol consumption• Genetic factors : Family history of P.U & blood group O• Psychological stress • Diet (pickles)• Others : seasonal variation & regional differences
Don’t be anger u `ll get PU
CLINICAL FEATURE of PUD
• History 1. Dyspepsia 2. Anorexia & weight loss ( more in GU )3. Vomiting 4. Sudden severe generalized abdominal pain ( perforation) 5. Haematemesis & Melina ( bleeding )
• Physical examination : Epigastric tenderness
PUD related complications 1. Hemorrhage 2. Perforation 3. Gastric outlet obstruction 4. Gastric CA
Diagnosis - History - Lab studies : 1. Routine tests : CBP , iron studies 2. Serum gastrin & gastric acid analysis 3. Tests for H. pylori - Radiographic ( barium study ) - Endoscopic (OGD) examination
Figure: D.U visualized by OGD
Classification of Treatment of P.U
Three groups of drugs
Drugs that decrease gastric acid secretion
Drugs that neutralize gastric acid
Drugs that enhance mucosal defense
I- Drugs that decrease gastric acid secretion:
1 -H2 receptor blockers
2 -Anticholinergics (antimuscarinic) 3- Proton pump inhibitors
ProglumideAChHistamine Gastrin
Adenyl cyclase
_ +
ATP cAMP
Protein Kinase (Activated)
Ca++
+
Ca++
Proton pump
KK+ H+
Gastric acid
Parietal cellLumen of stomach
Ranitidine
H2M3
__
+
PGE receptor
+
+
Gastrin receptor+
+
H2 - receptor blockers
Scientific Name
Trade Name
Relative Potency
Daily Dosage
Cimetidine Tagamet 1 x 800 mg H.S or 400 mg Bid
Ranitidine Zantac 4-10 x 300 mg H.S or 150 mg Bid
Famotidine Pepcid 20-50 X 40 mg H.S or 20 mg Bid
Nizatidine Axid 4-10 x 300 mg H.S or 150 mg Bid
INDICATION
1- G.U & D.U 2- Gastro esophageal reflex disease (GERD)
3- hypersecretory conditions : a- Zollinger – Ellison syndrome b- systemic mastocytosis c- multiple endocrine neoplasia
4- pre-anesthesia: (emergency and labour) to decrease incidence of mendelson's syndrome
5- Controlling symptoms of gastric CA6- Hiatus hernia7- Stress ulcer
SIDE EFFECT
• Sedation • Gynaecomastia , low sperm count , and
impotence (♂) & galactorrhea (♂)• Blood dyscrasia• Cholestatic effect, hepatitis +/- jaundice
Associated mostly with Cimetidine, rarely with Ranitidine, and not with Famotidine and Nizatidine
PROTON PUMP INHIBITORS
Omeprazole, Lansoprazole, Pantoprazole, Esomeprazole
Most effective drugs in antiulcer therapy
They inhibit H / K ATPase enzyme in parietal cellsIndications: P.U, GERD & Zollinger – Ellison syndrome.Side Effects: Erythema Multiformis (E.M), gynaecomastia,
bronchospasm, leukopenia, thrombocytopenia, photosensitivity & alopecia.
Anticholinergics:Pirenzepine (Gastrozepin)
Octerotide:Synthetic somatostatine analogueinhibits gastric and pancreatic secretions Used in Zollinger – Ellison syndrome & portal hypertension
PROTON PUMP INHIBITORS
Drugs That Neutralize Gastric Acid
Antacids:Basic substances that decrease acidity by
neutralizing HCL protecting ulcer from acid and pepsin by increasing PH (as pepsin is inactive when PH > 5)
MOA: They provide mucosal protection either
through stimulation of P.G production or by binding to identified injurious substance.
.
Drugs That Neutralize Gastric Acid
Classification:• Systemic: absorbable but cause metabolic alkalosis (Na
bicarbonate)• Non -systemic: not significantly absorbed, not affecting acid –
base balance (Mg and Al salts)
Side effects :• Al antacids → Constipation • Mg antacids → Osmotic diarrhoea• In renal failure Al antacids → Aluminum toxicity & Encephalopathy
Drugs That enhance enhance mucosal defense
.
1- Bismuth chelate :- Chelate with protein in the ulcer base forming a
coat that protects from acid, bile & pepsin - Stimulates the production of mucous and PG- Has antimicrobial activity against H.PyloriIndications: D.U & G.U (therapeutic activity equal to H2
blockers, But with less relapse of ulcer )Side Effects: - Darkening of tongue, teeth and stool - Arthropathy and encephalopathy
Drugs That enhance enhance mucosal defense
.
2. Sucralfate: (sulfated sucrose and Al OH)Sucrose becomes hydrated when contact with acid
to form viscous paste that protects ulcer from acid and pepsin
Stimulate PG synthesis and bind to pepsin and bile acid
Indications: P.U, GERD, GI bleeding, stress ulcer & ulcerative
colitisSide Effects: Constipation, vertigo & skin rash
Drugs That enhance enhance mucosal defense
.
3. Misoprostol: Synthetic analogue of PGE1 prevents G.U in patients taking NSAIDsinhibits acid secretion stimulated by histamine
Side Effects: Dysmennrohea and rash
4. Zinc salts
5. Liquorice
Combination Therapy of Peptic Ulcer
.
• Triple Therapy: Omeprazole plus Clarithromycin plus Amoxicillin / MetronidazoleGiven for 14 days followed by P.P.I for 4 – 6
weeks
• Quadruple Therapy: Omeprazole plus Bismuth plus Metronidazole
plus TetracyclineGiven when Triple Therapy fails