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Management of Acute Exacerbation of Peptic Ulcer Disease (PUD)
- 1. MANAGEMENT MANAGEMENT MANAGEMENT OF OF OF ACUTE ACUTE ACUTE EXERCEBATION EXERCEBATION EXERCEBATION OF OF OF PEPTIC PEPTIC PEPTIC ULCER ULCER ULCER DISEASE DISEASE DISEASE Presented by: Dr. Gbuchie Monica A. House Officer, Department of Internal Medicine, Rivers State University Teaching Hospital, Port Harcourt, Rivers State.
- 4. • Introduction • Management: • -History Taking & Clinical presentation • -Physical Examination • -Investigation/Diagnosis • -Treatment Proper: General & Specific • Patient Counselling • Complications • Conclusion OUTLINE
- 5. INTRODUCTION • Peptic ulcer disease (PUD) refers to a breach in the mucosal lining anywhere in the GI tract exposed to acid and pepsin. A break in superficial epithelial cells penetrating down to muscularis mucosa. • An acute exacerbation is defined as an acute and transient worsening of pre-existing symptoms in patients with PUD.
- 6. INTRODUCTION (contd) • The 2 most common forms are; • Duodenal ulcer • Gastric ulcer Duodenal Vs Gastric Ulcer
- 7. • Helicobacter pylori (mostly implicated) • Chronic use of NSAIDS (2nd commonest) • Steroids • Excessive alcohol intake • Cigarette smoking • Stress, etc • Bicarbonate secretion • Mucous secretion • Tight adherence between epithelial cells to prevent any acid leakage to the inside. • Good blood supply to the mucosa • Renewal of damaged epithelial cells. Aetiology/Risk factors | Protective factors
- 8. • Patients with acute exacerbation of PUD most commonly present with: • Severe epigastric pain • Dyspepsia (Chronic recurrent epigastric discomfort or pain, belching, bloating flatulence. • ALARM symptoms • ALARMS symptoms/ red flag signs of dyspepsia includes: • Anaemia • Unintentional weight Loss • lymphadenopathy • Anorexia • Recent onset/progressive Symptoms • Melena/Hematemesis • Swallowing difficulty- dysphagia, odynophagia • Others - Virchow's node; early satiety; family hx of gastric Ca; recurrent vomiting. CLINICAL PRESENTATION Symptoms depend on the ulcer location, ulcer etiology & patient’s age
- 9. PHYSICAL EXAMINATION • GENERAL EXAM: In painful distress, Pale, dehydrated, wasted, lymph node enlargement (suggestive of malignancy) • ABD EXAM: Epigastric tenderness, generalized tenderness, rebound tenderness, guarding, and rigidity in cases of perforated PUD • DRE: Melena stool, haematochezia, blummer- shelf (gastric ca) - A finding palpable on DRE that indicates that a tumor has metastasized to the pouch of Douglas. • There may also be signs and symptoms of shock, such as tachycardia, hypotension, anuria, etc
- 10. Gold standard is upper GI endoscopy: to reveal area(s) of ulceration, take biopsy for histology, brushing for cytology and culture for H. pylori. Full Blood Count (May show anaemia in pt. with GI bleeding). GxM blood if indicated in pts with Anaemia Serum E/U/Cr : May show electrolyte derangements esp. in pts presenting with vomiting. Clotting Profile: PT, aPTT, INR indicated in patients with active bleeding to r/o bleeding disorder. INVESTIGATIONS
- 11. Tests to diagnose the presence of H. pylori: INVASIVE: – Histology – Culture – Rapid urease test – Polymerase chain reaction NON-INVASIVE: – Serology to detect IgA &IgG antibodies against bacteria antigen – Fecal antigen test – 13C urea breath test (Most accurate for monitoring the eradication of PUD) INVESTIGATIONS (contd)
- 12. • Choice of treatment depends on etiology (e.g. HP, NSAIDs or psychological stress) and clinical presentation. Overall Treatment Goals: – Relief of symptoms – Healing of ulcer – Prevention of recurrence – Prevent or reduce complications General/ Non-pharmacological Therapy: • Eliminate or reduce psychological stress • Smoking and Alcohol cessation • Eliminate use of NSAIDs • Diet: Avoid refluxogenic foods(spicy, fried foods, beans,etc) that exacerbates pain and other dyspeptic symptoms. TREATMENT / THERAPY GOALS
- 13. Eradication of Helicobacter pylori infection: • The Triple therapy is widely employed and it involves the use of a proton pump inhibitor (PPI) with 2 antibiotics. E.g: Omeprazole 20mg + clarithromycin 500mg + Amoxicillin 1g taken 2 times daily for 14 days. • Quadruple therapy could also be used: Bismuth agent + Triple therapy. Suppression of acid secretion: • Proton pump inhibitors (PPIs) e.g. omeprazole, rabeprazole, esomeprazole. • Parenteral PPIs is the main stay in the management of acute exacerbation of PUD. • H2 receptor blockers e.g. cimetidine, ranitidine • Antacids are used for symptomatic relief of dyspepsia.
- 14. Mucosal protective agents: such as sucralfate, colloidal bismuth carbenoxolone and prostaglandin analogues such as misoprostol are used to promote ulcer healing especially NSAIDS related ulcers. Surgical intervention: • Employed in cases that are refractory to medical treatment or emergency case due to complications such as perforation. Most commonly performed procedures include: • Vagotomy and drainage by pyloroplasty, gastroduodenostomy (Bilroth1) or gastrojejunostomy (Bilroth ll). • Highly selective vagotomy • Vagotomy with antrectomy.
- 15. PATIENT COUNSELLING • Discuss with the patient the cause of the ulcer (e.g. H. pylori, NSAIDs, etc.) • Address risk factors (e.g. NSAID use, cigarette smoking, Alcohol, etc.) • Discuss the rationale behind the multi-drug regimens and the importance of adherence and sticking to the full course of therapy. • Counsel patient to look out for signs of GI bleeding (e.g. dark tarry stools, abdominal pain, vomiting with evidence of blood)
- 16. COMPLICATIONS Some complications of PUD may include: • Bleeding • Anaemia • Perforation • Electrolyte imbalance • Mortality (from acute bleeding)