1. •
Peptic ulcer disease.
•
2007
•
Peptic ulcer disease – ulceration of the gastroduodenal mucosa typically extending through the
muscularis mucosa. Ulcers occur within the stomach and/or duodenum and are often chronic in
nature.
•
Etiology of PU
•
Local infection - H. pylori;
•
Hypersecretion of HCl (ZOLLINGER-ELLISON SYNDROME);
•
NSAID-induced injury
•
Pathogenesis of PU.
Factors of agression and defence.
•
Balance Shay
(H.Shay, 1968)
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Classification of PU
•
Gastric ulcer
•
Duodenal ulcer
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Gastroduodenal ulcers
•
Classification of PU
Localization of ulcer
Duodenum
А:
•
Bulbus duodeni,
•
Postbulbar part.
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Anterior wall,
•
Posterior wall,
•
Lesser curvature,
•
Greater curvature.
Б:

2. •
Classification of PU
Localization of ulcer
Stomach
А:
•
Cardial part,
•
Subcardial part,
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Body of the stomach,
•
Antrum,
•
Pyloric part.
•
Anterior wall,
Б:
Posterior wall,
•
•
•
Lesser curvature,
Greater curvature
Classification of PU
Clinical form
•
Acute (revealed for the first time)
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Chronic
•
Classification of PU
Course
Latent
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Mild (rarely relapsing)
•
Moderate ( 1-2 timesyear relapsing)
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Severe (relapsing more than 3 timesyear ), with complications
•
Classification of PU
Phase
•
Exacerbation (relapse)

3. •
Damping exacerbation (incomplete remission)
•
Remission
•
Classification of PU
Morphological characteristic of ulcer
Ulcers’ size
•
small (less than 0,5 сm)
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middle (0,5 – 1 сm )
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large (1,1 – 3 сm )
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giant (more than 3 сm)
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Classification of PU
Functional characteristic of gastroduodenal system
•
With increased secretion
•
With normal secretion
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With reduced secretion
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Classification of PU
Complications
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Perforation;
•
gastrointestinal bleeding;
•
gastric outlet obstruction;
•
malignancy;
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Penetration ;
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Clinical picture of PU
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Clinical picture
Abdominal pain, classically epigastric with severity relating to mealtimes
•
Early pains
•
Late pains
•
Fasting pains
30 - 60 min after meals
1,5 - 2 hours
at night

4. Gastric dyspepsia
•
nausea
•
vomitting
•
heartburn
Intestinal dyspepsia
constipation
Astheno-vegetative syndrome
•
Instrumental diagnostics
•
Evaluation of gastric secretion
pH metry of stomach and duodenun
•
Severe hyperacidity (рН 0,9-1,2)
•
Hyperacidity (рН 1,3-1,5)
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Normacidity (рН 1,6-2,2)
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Mild hypoacidity (рН 2,5-3,5)
•
Severe hypoacidity (рН 3,6-6,0)
•
Achlorhydria (рН > 6,5)
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Methods for diagnosing Helicobacter Pylori
•
Invasive methods
1.
Bacteriologic test
2.
Hystologic method
3.
Quick urease test
4.
Polymerase chain reaction
5.
Phase contrast microscopy
•
Non-invasive methods
•
1. Serologic method
•
2. Polymerase chain reaction
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3. Urea breath test

5. •
Radiography
Direct signs:
•
Discrete crater (niche sign)
Indirect signs:
•
Scar deformation
•
Radiating mucosal folds(convergence of folds)
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Functional changes (slow or quick barium passage, duodenal dyskinesia, duodenogastral reflux,
local spasms)
•
Radiography
•
Esophagogastroduodenoscopy
Advantages:
1.
Confirmation of the disease
2.Establishment of the benign or malignant character of ulceration
3.
Visual and morphologic control of the ulcer healing
4.Revealing the concomitant lesions
•
of mucosa
Complications of PUD:
Complications, appearing suddenly and threatens to the patients’ life :
•
Gastrointestinal bleeding
•
•
Moderate: deficiency CBV 20-30%. Hb<70 g/l hematocrit 0,25-0,30.
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Severe: deficiency CBV 30-40%. Hb<50 g/L, hematocrit < 0,20.
•
•
Mild: deficiency CBV(circulating blood volume) < 20%. Hb<100 g/L, hematocrit > 0,30.
Very severe: deficiency CBV > 40%. Hb<50 g/L, hematocrit < 0,20.
Complications of PUD
Complications, appearing suddenly and threatens to the patients’ life :
•
Perforation
•
Complications of PUD
Complications, developing gradually and of chronic course:

6. •
Penetration
•
Complications of PUD
Complications, developing gradually and of chronic course:
•
Gastric outlet obstruction
•
•
•
Organic
Functional
Complications of PUD
Complications, developing gradually and of chronic course:
•
Malignancy
•
Treatment of PUD
•
Management considerations
•
The goals of ulcer therapy include relief of symptoms, ulcer healing and prevention of recurrence
and complications.
•
influence on the factors of aggression and/or defense;
•
In PUD, associated with H. pylori – eradication of HP;
•
Usage of medications, removing dyspeptic andor neurotic symptoms;
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Correction of pharmaceutical treatment with taking into account concomitant diseases;
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Indications to H. pylori eradication
Absolute indications
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Peptic ulcer disease (exacerbation, remission, complications)
•
chronic atrophic gastritis
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MALT-lymphoma
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Post-gastric cancer resection
•
Indications to H. pylori eradication
Relative indications
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Functional non-ulcer dyspepsia
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Gastro-esophago –reflux disease in long treatment with omeprazole

7. •
After surgical treatment of PU
•
Latent НР carrier for prophylaxis of MALT lymphoma and gastric cancer (patients’ wishes)
•
Patients who are first-degree relatives of gastric cancer patients
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Requirements to antihelicobacterial therapy
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Eradication of H.Pylori minimum in 80% cases in duration of therapy not more than 7-14 days;
•
Good compliance, low likelihood of adverse events,short duration, ease of administration, relatively
low cost;
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Patient must not stop taking the drugs himself.
•
Rules of antihelicobacterial therapy:
1. If usage of one scheme of therapy does not lead to eradication, than no need to repeat it once
more.
2. If used scheme did not lead to eradication, that means, that bacteria became resistant to one of the
components of therapy (clarithromycin, metronidazole).
3. If one, and than second scheme fails, than you must evaluate sensitivity of the H. pylori strain to all
spectrum of antibiotics.
4. Appearance of the bacteria in the organism after a year after treatment must be evaluated as relapse of
infection, not reinfection. In relapsing the more effective treatment must be used.
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Antihelicobacterial therapy
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Antihelicobacterial therapy
Bismuth-containing preparations
Colloidal bismuth subcitrate (DE-NOL) 240 mg 2 timesday 30 min before meals
bismuth subsalicylate
•
Antihelicobacterial therapy
Antisecretory drugs
•
ranitidine 150 mg 2 timesday
•
famotidine 40- 80 mgday
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omeprazole 20 - 40 mgday,
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lansoprazole 15 - 60 mgday ,
•
pantoprazole 40 - 80 mgday

8. •
rabeprazole 20 - 40 mgday
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Therapy of H.pylori
Antibacterial medications
•
tetracycline 500 mg q.I.d.,
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amoxicillin 1000 mg b.I.d. ,
•
clarithromycin 500 mg b.I.d ,
•
azithromycin 100 mg b.I.d ,
•
roxithromycin 150 mg b.I.d. ,
•
metronidazole 500 mg b.I.d ,
•
tinidazole 2000 mg/day.
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Eradication of Helicobacter pylori
(Maastricht Consensus 2005)
•
Eradication of Helicobacter pylori
(Maastricht Consensus 2005)
•
Control of eradication efficacy
•
Diagnosis – not earlier than 4-6 weeks after finishing antihelicobacter therapy or treatment with
another antibiotic and antisecretory drugs;
•
Diagnosis – by at least 2 methods (bacteriological, morphological and urease)
•
Cytologic method is not used for establishing the eradication.
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Indications to the surgical treatment of PUD
Absolute:
•
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Massive gastrointestinal bleeding;
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Decompensated gastric outlet obstruction;
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Suspicion of malignancy;
•
•
Perforation;
Penetration ;
Indications to the surgical treatment of PUD
Relative

9. •
Refractory to medical treatment ulcers;
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History of recurring bleeding;
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Penetrating unhealing ulcers;
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Compensated gastric outlet obstruction;
•
Callous ulcers without scarring for a long time;
•
frequent exacerbations of PUD, leading to decreased capacity for work and asthenisation of
the patient.