peptic ulcer disease.PPT

Aims:
Definition of peptic ulcer.
Location and symptoms.
Causes.
Types.
Complications and treatment.
Precautions.

Definition:
Peptic ulcer is a hole or open sore in the
lining of the stomach, duodenum
(beginning of the small intestine) or
oesophagus.

"peptic" refers to pepsin: a stomach
enzyme that breaks down protein.
An ulcer occurs when the lining of these
organs is corroded by acidic digestive
juices secreted by the stomach cells.

Location of peptic ulcer:
Ulcer may be found :
In oesophagus,
 stomach and
duodenum,
jejunum at multiple
levels (Zollinger Ellison
syndrome).

Symptoms
Abdominal discomfort usually occurs in
epigastric area (upper middle part of the
abdomen) radiating to the back described
as:
dull gnawing ache comes and goes for
several days
pain may increase when the stomach is
empty at night or half to three hours after
meal.
Pain is relieved by eating & antacid
medication.

Other symptoms:
Weight change
Fatigue

Other symptoms:
Chest pain
Burping

Other symptoms:
Nausea and Anorexia (common with
gastric ulcer)

Other symptoms:
Vomiting (relieves episodes of severe
pain due to evacuation of gastric acid
content).

Less common symptoms:
1-Constipation and 5% of the patients
with chronic duodenal ulcers has
predominantly colonic symptoms.

Less common symptoms:
2-Heartburn and eructation are also
commonly associated with ulcer activity.
NOTE: heartburn is so prominent that the
primary disease is thought to be
esophageal.

Emergency symptoms:
If you have any of these symptoms call
your doctor right away:
Sharp sudden persistent stomach.

Emergency symptoms:
Bloody or black stools.
Bloody vomit or vomit that looks like
coffee grounds.

NOTE:
They could be signs of a serious problem
such as:
Perforation when the ulcer burrows through the
stomach or duodenal wall.

NOTE:
 Bleeding when the ulcer blocks the path of food
trying to leave the stomach.

Causes of peptic ulcer:
While acid is still considered significant in
ulcer formation, the leading cause of ulcer
disease is currently believed to be
infection of the stomach by bacteria called
"Helicobacter pyloridus" (H. pylori).

Stress increases HCl
secretion.

Chronic use of anti-inflammatory
medications, commonly referred to as
NSAIDs (Nonsteroidal anti-
inflammatory drugs).

H. Pylori Bacterium (helicobacter pylori(
The H. pylori bacteria
excretes the enzyme urease,
which converts urea into
ammonia and bicarbonate. The
release of ammonia ‘neutralize’
the acidic environment in the
stomach, which explains
the difficulty in destroying the
H. pylori bacterium.! Ammonia
is toxic to the epithelial cells
and damages them; hence the
beginning of a stomach ulcer
takes its course.

Diagnosing H. pylori:
H. pylori is diagnosed through:
 blood,
 breath,
 stool,
 and tissue tests.

Blood tests are
most common. They
detect antibodies to
H. pylori bacteria.
Blood is taken at the
doctor's office
through a finger stick.

Urea breath tests are an
effective diagnostic method
for H. pylori. They are also
used after treatment to see
whether it worked. In the
doctor's office, the patient
drinks a urea solution that
contains a special carbon
atom. If H. pylori is present, it
breaks down the urea,
releasing the carbon. The
blood carries the carbon to
the lungs, where the patient
exhales it. The breath is
accurate.

Stool tests detect H.
pylori infection in the
patient's fecal matter.
Helicobacter pylori
stool antigen (HPSA)
test is accurate for
diagnosing H. pylori .
Tissue tests are
usually done using the
biopsy sample that is
removed with the
endoscope.

No one knows for sure how H. pylori
spreads, so prevention is difficult.
Researchers are trying to develop a
vaccine to prevent infection.
Note: H. pylori can be transmitted from
person to person through close contact
and exposure to vomit.

NSAIDsNSAIDs
NSAIDs are medications for arthritis
and other painful inflammatory conditions
in the body. Aspirin, Ibuprofen (Motrin),
Naproxen (Naprosyn), and Etodolac
(Lodine) are a few of the examples of this
class of medications. NSAIDs cause
ulcers by interfering with prostaglandins in
the stomach & prevent PGE2 synthesis.

ProstaglandinsProstaglandins
Prostaglandins are substances which are important
in helping the gut linings resist corrosive acid
damage.
-local prostaglandins production PGE2.
HCl Damaging factors.
Bicarbonate (production of gastric bicarbonate
which is trapped in the mucus layer thus creating a
PH gradient from 1-2 at gastric lumen, 6-7 at surface
of mucosa).
Mucus production (mucus mucopolysaccharides
resistant to action of proteolytic enzymes).
Protective
factors

CofactorsCofactors
Cigarette smoking is
an important cofactor of
ulcer formation and ulcer
treatment failure.
Cigarette smoking
increases the risk of
ulcer complications.
Nicotine is a ganglionic
stimulant so it stimulates
vagal nerve and increase
HCl secretion through
acetylcholine.

 alcohol intake disrupts mucus secretion
and cause mucosal damage.

Coffee
 Colas,
spicy foods,
and caffeine

Types of Peptic UlcerTypes of Peptic Ulcer::
Duodenal
Gastric
Oesophagal
Zollinger Ellison syndrome (severe peptic
ulcer+gastric hyperacidity, gastrinoma:
islet cell tumor in pancreas)
Curling's ulcer

Duodenal and Gastric UlcersDuodenal and Gastric Ulcers::

Duodenal ulcer Gastric ulcer
-Incidence
Age 30-60 Usually 50 years and
above
♀:♂2-3:1 ♂:♀ 1:1
80% of peptic ulcers
are duodenal
15% of peptic ulcers
are gastric
Comparison between Duodenal andComparison between Duodenal and
Gastric UlcerGastric Ulcer::

-Signs and
Symptoms
Hypersecretion of
HCl
Hyposecretion of
HCl
Weight gain Weight loss
Pain 2-3 hrs after meal;
often awakened btw 1-2
AM; ingestion of food
relieves pain
Pain occurs 12-1 hr
after meal; rarely
occurs at night; may
be relieved by
vomiting; ingestion of
food does not help,
sometimes increases
pain
Vomiting uncommon Vomiting common
It perforates more than
gastric ulcer
Hemorrhage more
likely to occur than
with duodenal ulcer.

-Malignancy
rare Occasionally takes
place
-Risk factors H.Pylori, alcohol,
smoking, cirrhosis,
stress
H.Pylori, gastritis,
alcohol, smoking,
NSAIDs, stress

Esophageal UlcerEsophageal Ulcer
An esophageal ulcer is a hole in the lining
of the esophagus corroded by the acidic
digestive juices secreted by the stomach
cells.
An esophageal ulcer is usually located in
the lower section of esophagus. Esophageal
ulcers are not contagious.
 Esophageal ulcers may be a symptom of
another disease or condition.. Bleeding from
esophageal ulcers may cause iron deficiency
anemia.
It is often associated with chronic GERD.

 Gastroesophageal reflux disease is the
abnormal backflow of stomach acid and
juices into the esophagus.
Gastroesophageal reflux disease occurs
in infants too. Infants who have
gastroesophageal reflux disease may not
gain weight, may have respiratory
problems and may develop more slowly.

This backflow occurs when the valve
between the lower end of the esophagus and
the stomach does not close tightly enough.

72 year-old woman with scleroderma and
associated chronic reflux, with severe
distal esophagitis, stricture formation and
extensive, deep ulceration.
Illustrated examplesIllustrated examples::

83 year-old man with dysphagia, dyspepsia.
Endoscopy revealed twin "kissing" ulcers
just above a lower esophageal stricture
through which the endoscope would not
pass until after gentle balloon dilation.

70 years old woman with hematemesis,
Endoscopy demonstrated a long, deep
benign distal esophageal ulcer.

NoteNote::
 More than half of patients with AIDS will
develop esophageal disease. The most
common pathogenic organisms causing
esophageal symptoms in HIV-infected
patients include Candida, herpes simplex
virus, and cytomegalovirus, but bacterial
infections with Mycobacterium
tuberculosis and parasitic infections with
Leishmania protozoa have also been
reported

Zollinger-Ellison syndromeZollinger-Ellison syndrome::
 A large amount of
excess acid is produced in
response to the
overproduction of the
hormone gastrin, which in
turn is caused by tumors
on the pancreas or
duodenum. These tumors
are usually malignant,
must be removed and acid
production suppressed to
relieve the recurrence of
the ulcers.

Curling'sCurling's ulcerulcer
Curling's ulcer is an acute peptic ulcer of
the duodenum resulting as a complication
from severe burns when reduced plasma
volume leads to sloughing of the gastric
mucosa.
These stress ulcers were once a common
complication of serious burns, especially
common in child burn victims. They result in
perforation and hemorrhage and had
correspondingly high mortality rates.

Diagnosis or Investigations:
CBC: complete blood count to detect anemia
(bleeding from esophageal ulcers may cause
iron deficiency anemia.)
Fecal analysis because blood may be present
in feces.
Endoscopy is an exam that uses an
endoscope, a thin, lighted tube with a tiny
camera on the end. If an ulcer is bleeding, the
doctor can use the endoscope to inject drugs
that promote clotting or to guide a heat probe
that cauterizes the ulcer.
Bleeding:
As an ulcer erodes the muscles
of stomach, or duodenal wall,
blood vessels may also be damaged,
which causes the bleeding.
Over a period of time, the patient
becomes anemic.
Can be treated endoscopically by
Locating the ulcer &cauterizing the BV
With heating device
or injected with material
to stop bleeding.
Perforation:
Sometimes,
ulcer eats a hole
in wall of the stomach, or duodenum.
Bacteria & partially digested food
can spill through the opening
into the sterile abdominal Cavity(paritonium).
This causes paritonitis,an inflammation of the
abdominal cavity & wall.
Immediate hospitalization
and surgery is usually required.
ComplicationsComplications
Narrowing and
obstruction:
Ulcers located at the end of stomach
where the duodenum is attached
may cause swelling & scarring
this can narrow or close the
intestinal opening
& can prevent food from leaving stomach
& entering the SI.As a result,
a person may vomit the
contents of the stomach.
Endoscopic balloon dilation
May be done.

Barium X-ray examination (less
expensive method of diagnosing
peptic ulcer).
But X-ray examination does have
some limitations:
It is unable to define mucosal
disease ex: gastritis.
It is not definitive in
differentiating benign from
malignant gastric ulcer.
It cannot delineate superficial,
subacute gastric or duodenal
erosions.
It cannot define complete healing
of an ulcer.
Furthermore, as an ulcer heals,
the surrounding tissue, especially
in the duodenum, becomes
scarred and deformed and
radiologic assessment of activity
of the ulcer becomes more
difficult.

Receptors present on the cellReceptors present on the cell
membrane of parietal cells in stomach:membrane of parietal cells in stomach:
M1 Receptors:
stimulated by acetylcholine secreted from the para-sympathetic
nerve endings (vagus nerve).
Gastrin Receptors:
stimulated by gastrin hormone from mucosa of stomach and
duodenum into the blood.
presence of food causes distention of the stomach this will
cause stimulation of mucosa so gastrin hormone increases in blood
and parietal cells increase the secretion of HCl.
H2 Receptors:
stimulated by histamine secreted from mast cells in stomach.

MedicationMedication
SurgerySurgery
ChangingChanging
Life styleLife style
Treatment

To relieve the
symptoms
(pain, vomiting,
blood loss).
To prevent
recurrence of
ulcer by
maintenance
therapy.
To prevent
complications
of ulcer.
To promote
healing
of ulcer.
To eliminate
the source
of problem.
Aims
of
treatment

DRUGS
Anti secretory
Drugs:
they reduce
gastric
acid secretion
Cytoprotective
drugs having
mucosal
Protective
properties
H2 blocker:
first line
of treatment
of
peptic ulcer
Anti-
muscarinic
drugs
Proton
pump
inhibitors
Sucralfates Bi-chelates
Misoprostol Antacids
Antibiotics:
To kill H. Pylori

DRUGS
Anti secretory
Drugs:
they reduce
gastric
acid secretion
H2 blocker:
first line
of treatment
of
peptic ulcer
Anti-
muscarinic
drugs
Proton
pump
inhibitors

H2 -AntihistamineH2 -Antihistamine
Mode of action :
These are competitive
antagonists with histamine
on H2 receptors found on
the parietal cells of the
stomach so they can reduce
gastric acid secretion.
They are given as first line
of treatment for 4 weeks
then the patient is examined
to see if ulcer healed.
If ulcer is healed so the
patient moves to lower
dosage regimen such as
maintenance therapy.
If ulcer is not healed so
shift to another line of
treatment.
Side effects:
constipation, diarrhea,
H2
antihistaminics
Ranitidine Cimetidene
Nazitidine Famotidine
Axid
(amp+cap)
Apo-famotidine
Apo-cimetidine CimetrilApo-ranitidine Ranicux
Rantag Zantac
Gastrodomina Pepcid
Famodar
Neutronorm

Proton Pump InhibitorsProton Pump Inhibitors
Mode of action:
They irreversibly inhibit H+
pump or H+/K+ ATPase
which is an enzyme in the
cell membrane of oxyntic or
parietal cells, they block the
final step for HCl secretion.
Regular use of these can
cause achlorohydria
because they act on HCl
formation not on receptors
that increase HCl secretion.
They are the most potent
anti-secretory drugs.
Side effects:
constipation, diarrhea, colic,
nausea.
P. pump
inhibitor
Rabeprazole Pantoprazole
Omeprazole lansoprazol
Gastrimut Risek
Epirazole Gastrazole
Omepral Oprazole
Pariet Inipomp
Takepron Lanzor
Ulstop Zimor
Esomeprazole
Nexium
Rabec
Lanzomide
Omedar Omizec
Omiz

Antimuscarinic DrugsAntimuscarinic Drugs
Mechanism of action:
they are selective M1 antagonists.
They are used in combination with H2
blocker because histamine is the main
mediator for HCl secretion.

DRUGS
Cytoprotective
drugs having
mucosal
Protective
properties
Sucralfates Bi-chelates
Misoprostol Antacids

SucralfateSucralfate
it is the aluminum salt of sucrose octasulfate
i.e. sulfated sucrose + Aluminum hydroxide.
Trade name:sucrate gel (sucralfate oral gel)
Mode of action:
It has a mucosal protective action, it increases mucus
production, increases bicarbonate, and increases
prostaglandin synthesis.
The drug prevents the negative effects of smoking on ulcer
healing so it is the first line treatment in case of smokers in
combination with antisecretory drugs(H2 blockers).
Moreover, in the acid medium of the stomach, it forms a gel
that adheres to the surface of ulcer and provides physical
protection. Given orally, it has minimum systemic absorption
and it's excreted in feces.
Side effects:
• constipation due to aluminum
• 3 to 5% of aluminum salt can be absorbed and this will cause
aluminium toxicity, so it is not used as maintenance therapy.

Bismuth chelatesBismuth chelates::
Mode of action:
they have mucosal protective activity
 increase prostaglandins
 increase bicarbonate
 increase mucus production
They have toxic effect on Helicobacter pylori (bactericidal)
can be used as first line treatment with H2 blocker if
helicobacter infection is positive.
Side effects: blackening of the tongue, teeth, and
stools.
N.B: Certain % of bismuth is absorbed so this causes
bismuth toxicity so it is not used for maintenance therapy.

Misoprostol (CytotecMisoprostol (Cytotec((
Mechanism of action:
It causes mucosal protection by:
•Increasing mucus and bicarbonate production.
•Decreasing gastric HCl secretion
Uses:
It is only used for prevention of NSAID_induced ulceration in patients
with high risk
•Elderly
•Smokers
•Patients with history of gastric bleeding.
When NSAIDs are stopped, discontinue misoprostol.
Side effects:
•Gastro intestinal disturbances (vomiting, diarrhea, colic) due to
prostaglandin induced smooth muscle contraction.
•Gynecological disturbances (spotting,dysmennorhea).
•Uterine contractions (contra-indicated in pregnancy because they cause
abortion).

AntacidsAntacids
Mode of action: used for symptomatic relief.
They act via neutralization of the gastric HCl.
Antacid Adverse rxn
Al hydroxide constipation
Mg(hydroxide
or trisilicate)
diarrhea
So a mixture of aluminum and magnesium is used
in combination with H2 blocker and to relieve the
symptoms of hyperacidity.

Unsuitable antacidsUnsuitable antacids
Antacid Unsuitable due to
Sodium bicarbonate salt production of CO2 that
stimulates gastrin
secretion so increases
HCl and produces
flatulence &its rapidly
absorbed and cause
metabolic alkalosis.
Calcium carbonate production ofCO2 and
CaCl2 that causes
hypercalcemia.

DRUGS
Antibiotics:
To kill H. Pylori

AntibioticsAntibiotics
 H. pylori can be very difficult to completely
eradicate. Treatment requires a combination of
several antibiotics, sometimes in combination with a
proton-pump inhibitor, H2 blockers or Bi-chelate.
Without such treatment there is an eighty percent
chance the ulcer will reoccur within one year.
Eradication of H. pylori prevents the return of ulcers
(a major problem with all other ulcer treatment
options) Elimination of this bacteria may also
decrease the risk of developing gastric cancer in the
future.
An effective combination would be Amoxicillin +
Metronidazole + Pantoprazole.

Surgery:
Surgery may be necessary if you have
bleeding, a perforation, or an obstruction.
Surgical options include the following:
Endoscopic surgery
Vagotomy and drainage
Pyloroplasty
Gastroduodenostomy
Gastrojejunostomy
Highly elective vagotomy
Vagotomy with antrectomy

Dietary changes that may be helpful:Dietary changes that may be helpful:
SUGARSUGAR & SALT& SALT
People with ulcers have been
reported to eat more sugar than
people without ulcers.
Salt is a stomach and intestinal
irritant. Higher intakes of salt have
been linked to higher risk of stomach
ulcer.
 As a result of these reports, some
doctors suggest that people with ulcers
should restrict the use of both sugar
and salt, although the benefit of such
dietary changes remains unknown.

Many years ago, researchers
reported that cabbage Juice
accelerated healing of peptic ulcers.
Drinking a quart of cabbage juice per
day was necessary for symptom relief
in some reports.
Carrot juice may be added to
improve the flavor.

Advice For Duodenal ulcer PatientsAdvice For Duodenal ulcer Patients
Fiber slows the movement of food and
acidic fluid from the stomach to the
intestines, which should help those with
duodenal ulcer.

Lifestyle changes that may be helpful:Lifestyle changes that may be helpful:
Aspirin and related drugs
(NSAID), alcohol, coffee, and tea
can interfere with the healing of
peptic ulcers. Smoking is also
known to slow ulcer healing.
 Whether or not an ulcer is caused
by infection, people with peptic ulcer
should avoid use of these
substances.

Nutritional supplements that may beNutritional supplements that may be
helpful:helpful:
Vitamin A is needed to heal the
linings (m.m) of the stomach and
intestines.
High dose should not be taken by a
pregnant woman, by a woman who
could become pregnant, or by
anyone else without careful
supervision from a doctor.
The effect of lower amounts of
vitamin A has not been studied in
people with peptic ulcer.

ZINCZINC
Zinc is also needed for the repair of
damaged tissue and has protected against
stomach ulceration in animal studies.
Copper must be taken to avoid copper
deficiency that would be induced by the
zinc supplementation.

GlutamineGlutamine
Glutamine, an amino acid, is the
principal source of energy for cells that
line the small intestine and stomach.
Glutamine has also prevented stress
ulcers triggered by severe burns in
another preliminary study.

VITAMIN CVITAMIN C
Little is known about the effects of
Vitamin C in peptic ulcer cases.
Vitamin C may also help eradicate
H. pylori in people with gastritis.
Vitamin C may one day prove to
have a therapeutic effect for people
with peptic ulcer; however, further
research in this area is needed.

Herbs that may be helpful:
Licorice root has a long history of use
for soothing inflamed and injured mucous
membranes in the digestive tract. Licorice
may protect the stomach and duodenum
by increasing production of mucin.
 Flavonoids in licorice may also inhibit
growth of H. pylori.

CHAMOMILECHAMOMILE
Chamomile has a soothing effect on
inflamed and irritated mucous
membranes. It is also high in the
flavonoid apigenin, another flavonoid
that has inhibited growth of H. pylori.
Chamomile is also available in
capsules.
Calendula is another plant with anti-
inflammatory and healing activities
that can be used as part of a traditional
medicine approach to peptic ulcers.
The same amount as chamomile can
be used.

Marshmallow is high in mucilage.
High-mucilage-containing herbs have a
long history of use for irritated or inflamed
mucous membranes in the digestive
system.

GARLICGARLIC
Garlic has been reported to have anti-
Helicobacter activity.

PreventionsPreventions::
To decrease risk of ulcer from H.
pylori infection:
Wash your hands after using the
bathroom and before eating or
preparing food.
Drink water from a safe source.
Don’t smoke. Cigarette, smoking
increases the chances of getting
an ulcer.

PreventionsPreventions::
To decrease the risk of ulcer from
NSAIDs:
Use other drugs when possible for
managing pain.
Take the lowest possible dose.
Do not take longer than needed.
Do not drink alcohol while taking
the drugs.

peptic ulcer disease.PPT

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