06. PEPTIC ULCER DISEASE

PEPTIC ULCER DISEASE Peptic ulcer diseas-Tran Ngoc Anh MD Objectives PEPTIC ULCER DISEASE 1.Recognize the typical clinical presentation and risk factor for PUD 2.Understand pathophysiology of PUD focusing on HP 3.Describe an appropriate diagnostic plan 4.Prescribe an appropriate therapeutic regime Peptic ulcer diseas-Tran Ngoc Anh MD GENERAL CONSIDERATIONS  An ulcer: disruption of the mucosal integrity of the stomach and/or duodenum (surface >5mm in size, depth to the submucosa)  Occur: Stomach and/or duodenum  Chronic Peptic ulcer diseas-Tran Ngoc Anh MD ETIOLOGY and PATHOPHYSIOLOGY Common • Helicobacter pylori infection • NAIS • Stress- related mucosal damage Uncommon • Zollinger Ellison • Tumors (Cancer, lymphoma) • Viral infections • Radiation/che motherapy • Vascular insufficiency Rare • Crohn’s disease • Helicobacter helimannil • Idiopathic Peptic ulcer diseas-Tran Ngoc Anh MD ETIOLOGY and PATHOPHYSIOLOGY CLINICAL FEATURES 1.Symptoms -Abdominal pain. 10%PU with a complication: bleeding, perforation, obstruction -Epigastric pain-Most common subtype: burning, gnawing discomfort: +DU: occurs 90 min to 3h after a meal; relieved by antacids or food. Awakes from sleep +GU: discomfort precipitated by food -Nausea, Weight loss; more commonly in GU -Dyspepsia including belching, bloating Peptic ulcer diseas-Tran Ngoc Anh MD CLINICAL FEATURES  Common risk factor for gastric mucosa disruption: HP, NSAIDS/ASA(event at low dose), Coffe caffeine, Ethanol, Tobacco, Severe Physiology stress, Steroids  Clinical pearls: NSAID: gastritis or ulcer silent. Ve Dyspeptic are non specific: 20-25%  NSAIDS: 15%of patients longterm NSAIDS (Piroxicam, Feldene, Ketorolac, Toraldo, Celceb, Indomethacine, Ibuprofen, Selective COX2) Peptic ulcer diseas-Tran Ngoc Anh MD CLINICAL FEATURES 2.Physical examination: few, non specific Epigastric tenderness (20% in right of the midline) Discovering evidence of ulcer complication Tachycardia, orthostasis: dehydration secondary to vomiting, active gastrointestinal blood loss Severely tender, Boardlike abdomen: perforation Succussion splash indicates retained fluid in the stomach: gastric outlet obstruction Peptic ulcer diseas-Tran Ngoc Anh MD CLINICAL FEATURES • Epigastric pain • Nausea • Fullness, Bloating • Early satiely • Nocturnal pain Typical symptoms • Anemia • Hematemesis, Melena, Heme+ stool • Anorexia, weight los • Severe abdominal pain Alarm symptoms Peptic ulcer diseas-Tran Ngoc Anh MD LABORATORY FINDING Radiographic-Barium study Endoscopy Others Peptic ulcer diseas-Tran Ngoc Anh MD [...]...LABORATORY FINDING 1.Barium studies -Older single contrast barium meals: 80% Double :90% -Not good in small ulcer -DU: Well demarcated crater in the bulb -GU: discrete with radiating mucosal folds origanating from the ulcer margin -Ulcer >3cm with mass: malignant Peptic ulcer diseas-Tran Ngoc Anh MD LABORATORY FINDING LABORATORY FINDING 2.Endoscopy  Most sensitive, specific  Permet: direct... useful for early follow up, False (-) with PPI, Antibiotics, Bismuth Stool antigen >90/>90 Inexpensive, convenient; not establishd for eradication but promising Peptic ulcer diseas-Tran Ngoc Anh MD COMPLICATIONS Gastrointestinal bleeding Peptic ulcer diseas-Tran Ngoc Anh MD Perforation Gastric outlet obstruction COMPLICATIONS 1 Gastrointestinal bleeding: Most common  15%, >60; Use NSAIDS  Tarry stools,... severe, generalized abdominal pain  Penetration-DU: Pancreas pancreatitis -GU: Left hepatic lobe Peptic ulcer diseas-Tran Ngoc Anh MD COMPLICATIONS 3.Gastric outlet obstruction  The least common complication  1-2% patients  Pain worsening with meal, nausea, vomiting of undigested food Weight loss Peptic ulcer diseas-Tran Ngoc Anh MD TREATMENT INTERNAL MEDECINE • Acid neutralizing/inhibitory drugs... agents • Therapy of H.Pylori • Therapy of NSAID related gastric or duodenal SURGICAL • Fail of internal medecine • Complication Peptic ulcer diseas-Tran Ngoc Anh MD TREATMENT Acid neutralizing/inhibitory drugs Antacids • Mix Aluminum, Mg hydroxide • Maalox, Gastropulgite Peptic ulcer diseas-Tran Ngoc Anh MD H2 antagonists • Use primarily in UD not associated with HP • Inhibit the H2 receptor of parietal... 300mghs Proton pump inhibitor Omeprazole Lansoprazole Rebeprazole Pantoprazole Esomeprazole 20mg/d 30mg/d 20mg/d 40mg/d 20mg/d Peptic ulcer diseas-Tran Ngoc Anh MD Dose Mucosal protective agents Drug type Sucralfate Prostaglandin analogue Bismuth containing compounds Peptic ulcer diseas-Tran Ngoc Anh MD Examples Sucralfate Misoprostol Bismuth subsalicylat BBS Dose 1g qid 200 µg qid TREATMENT  Cytoprotective... defense, repair, Enhance mucous HCO3, stimulate mucosal blood flow, mucosal cell turnover • 200 µg qid Peptic ulcer diseas-Tran Ngoc Anh MD Bismuth containing compounds • The mechanism is unclear: prevention of futher pepsin/HCl induced damage, HCO3, mucous secretion TREATMENT PUD cause HP Peptic ulcer diseas-Tran Ngoc Anh MD PUD cause NSAID Helicobacter pylori infection treatment regimens Combination... THERAPY REGIMEN 1 of 5 PPI above or Cimetidine 300mg po qid Famotidine 20mg po bid Nizatidine 150mg po bid Ranitidine 150mg po bid Peptic ulcer diseas-Tran Ngoc Anh MD Metronidazole 250mg qid +Tetracyclin 500mg po qid Bismuth 525mg po qid BMT-PPI or H2RA NSAID-Induced Ulcer Treatment Regimens Treatment Option Drug use Example Discontinuation of NSAID PPI Dexlansoprazole 3060mg Esomeprazole 20-40mg... LABORATORY FINDING 2.Endoscopy  Most sensitive, specific  Permet: direct visualization of the mucosa, tissue biopsy-rule out malignancy, H.pylori 3.Others -CBC: acute/chronic blood loss -HP test Peptic ulcer diseas-Tran Ngoc Anh MD LABORATORY FINDING LABORATORY FINDING Test Se/Sp Comments Invasive Rapid urease 80-95/95-100 Simple, False (-) with PPI, Antibiotics, Bismuth Histology 80-90/.95 Culture... Famotidine, Nizatidine, Ranitidine Prophylactic therapy Mucosal protective agent PPI Selective COX2 inhibitor Sucralfate 1g Same as PPI above Continuation of NSAID PPI Same as PPI above H.P Multiple Peptic ulcer diseas-Tran Ngoc Anh MD . PEPTIC ULCER DISEASE Peptic ulcer diseas-Tran Ngoc Anh MD Objectives PEPTIC ULCER DISEASE 1.Recognize the typical clinical presentation. good in small ulcer -DU: Well demarcated crater in the bulb -GU: discrete with radiating mucosal folds origanating from the ulcer margin -Ulcer >3cm with mass: malignant Peptic ulcer diseas-Tran. los • Severe abdominal pain Alarm symptoms Peptic ulcer diseas-Tran Ngoc Anh MD LABORATORY FINDING Radiographic-Barium study Endoscopy Others Peptic ulcer diseas-Tran Ngoc Anh MD LABORATORY FINDING 1.Barium