Peptic ulcer disease refers to ulcers in the stomach or duodenum caused by an imbalance of digestive fluids. Common causes include infection with H. pylori bacteria and use of NSAIDs like aspirin. Symptoms may include abdominal pain, nausea, vomiting, or blood in stool. Treatment involves eradicating H. pylori with antibiotic combinations, managing NSAID use, and prescribing proton pump inhibitors to reduce acid production and promote healing. Proton pump inhibitors are also used to treat gastroesophageal reflux disease, which occurs when stomach acid backs up into the esophagus.

1. Peptic ulcer
By Dr.Bassem Alaa el-din

3. Secretion of HCl in stomach

4. What Is Peptic Ulcer Disease?
 Peptic ulcer disease refers to painful
sores or ulcers in the lining of the
stomach or first part of the small
intestine, called the duodenum.

5. Etiology
 No single cause has been found for ulcers. However, it
is now clear that an ulcer is the end result of an
imbalance between digestive fluids in the stomach and
duodenum. Ulcers can be caused by:
 Infection with a type of bacteria called
Helicobacter pylori (H. pylori)
 Use of painkillers called nonsteroidal anti-
inflammatory drugs (NSAIDs ),such as aspirin,
naproxen (Aleve, Anaprox, Naprosyn, and others),
ibuprofen (Motrin, Advil, Midol, and others), and
many others available by prescription. Even safety-
coated aspirin and aspirin in powered form can
frequently cause ulcers.

6. Etiology
 Genetic
 Mind
 Spicy food
 Smoking
 Neurological
 Vagus nerve
 Increased acid secretion
 Age
 Alcohol

7. Symptoms of an ulcer
 An ulcer may or may not have
symptoms. When symptoms occur,
they may include:
 A gnawing or burning pain in the middle or upper stomach
between meals or at night
 Bloating
 Heartburn
 Nausea or vomiting

8. In severe cases, symptoms can
include:
 Dark or black stool (due to bleeding)
 Vomiting blood (that can look like
"coffee-grounds")
 Weight loss
 Severe pain in the mid to upper
abdomen

9. Clinical manifestations
 Complications: Haemorrhage, anemia,
pyloric stenosis
 Relapse is ↓ by eradication of H.
pylori

10. Treatment

11. A) Helicobacter pylori

12. A) Helicobacter pylori eradication
The highest eradication rates was achieved by 1 week twice daily triple therapy consisting of a PPI (or
RBC) & 2
 specified antibiotics
 RBC= ranitidine bismuth citrate
 Triple therapy
 1. OCA: Omeprazole 20mg, Clarithromycin 500mg, Amoxicillin
1g
 2. OCM: Omeprazole 20mg, Clarithromycin 500mg,
Metronidazole 400mg (Tinidazole in resistant individuals)
 Failure of the first line regimen necessitates the shift to another
triple therapy or starting quadruple regimen.
 Quadruple therapy
 Bismuth subsalicylate,Metronidazole, Tetracycline or Amoxicillin
& PPI.

13. B) Treatment of NSAID-
associated
ulcersUsing standard doses of:
 1. Proton pump inhibitors (PPIs)
 2. H2-receptor antagonist
 3. Misoprostol
 4. Sucralfate
 Due to their rapid rate of ulcer healing,
PPIs are drugs of choice for patients with
large or complicated NSAID-induced
ulcers
 Healing is impaired if NSAID is

14. Prophylaxis of NSAID
ulceration
 Patients with chronic rheumatological
conditions require long-term NSAID
treatment, in this case, the lowest
effective dose should be used.
 It is recommended to take PPI for
prophylaxis of ulceration in patients
who must continue NSAIDs.

15. What Is Gastroesophageal
Reflux?
 Gastroesophageal refers to the stomach and
esophagus. Reflux means to flow back or return.
Therefore, gastroesophageal reflux is the return
of the stomach's contents back up into the
esophagus.
 In normal digestion, the lower esophageal
sphincter (LES) opens to allow food to pass into
the stomach and closes to prevent food and
acidic stomach juices from flowing back into the
esophagus. Gastroesophageal reflux occurs
when the LES is weak or relaxes inappropriately,
allowing the stomach's contents to flow up into
the esophagus.
 The severity of GERD depends on LES
dysfunction as well as the type and amount of
fluid brought up from the stomach and the
neutralizing effect of saliva.

16. GERD symptoms
 Heartburn is the characteristic
symptom, & the patient may complain
of
 acid regurgitation & dysphagia.

17. GERD Treatment
 The most effective therapy is
standard dose of PPI therapy
 Long-term management should
consist of least expensive but effective
drug

18. 1- Proton pump inhibitors
(PPI)
 They control gastric acid secretion by
inhibition of gastric H+, K+ ATPase,
which is responsible for the final step
in gastric acid secretion.
 Under acidic conditions, they are
converted to their active form. Then,
irreversibly, they bind the proton
pump, inhibiting acid secretion.

19. PPI(Esomeprazole)
 Esomeprazole is the 1st PPI developed as a single
optical isomer.
 It is the S-isomer from the racemic
mixture(omeprazole)
 Compared with Omeprazole,Esomeprazole
provides greater & more sustained acid control.

20. PPI (Omeprazole)P&G

21. PPI(Omeprazole)

22. PPI(Pantoprazole)

23. Can Prilosec be taken in place of
Protonix for heartburn (GERD)?
 One example for Prilosec versus
Protonix is if Plavix (clopidogrel) has
been prescribed. Plavix is routinely
given after a heart attack and used to
prevent blood clots in heart. The
problem is that Prilosec has recently
been shown to cause Plavix to work
less effectively while Protonix does not
appear to affect it significantly.

24. PPI(Lansoprazole)Novartis

25. H2 receptor antagonists
 Histamine H2-receptor antagonists, also known
as H2-blockers, are used to treat duodenal ulcers
and prevent their return. They are also used to
treat gastric ulcers and for some conditions, such
as Zollinger-Ellison disease, in which the
stomach produces too much acid. In over-the-
counter (OTC) strengths, these medicines are
used to relieve and/or prevent heartburn, acid
indigestion, and sour stomach. H2-blockers may
also be used for other conditions as determined
by your doctor.
 H2-blockers work by decreasing the amount of
acid produced by the stomach.
 H2-blockers are available both over-the-counter
(OTC) and with your doctor's prescription.

26. H2 Receptors Blockers
 1. Cimetidine,
 2. Ranitidine,
 3. Famotidine,
 4. Nizatidine

27. Ranitidine

28. Other medications
 Bismuth subsalicylate (Stomach-lining
protector)
 Sucralfate At pH < 4.0, it forms a sticky
viscid gel that adheres to the ulcer
surface & results into physical protection.
 Antacids
 Misoprostol is a synthetic prostaglandin
E1 (PGE1) analogue ,It stimulates
increased secretion of the protective
mucus that lines the GIT&↑ mucosal
blood flow↑ mucosal integrity.