The document discusses current trends in the management of ulcers, including opportunities and challenges. It begins by defining different types of ulcers and erosions. Common causes of peptic ulcers are Helicobacter pylori infection, NSAID use, smoking, and stress. Diagnosis involves endoscopy, biopsy, and testing for H. pylori. Treatment involves acid suppression therapy, H. pylori eradication treatment, and avoiding NSAIDs. Recurrent or refractory ulcers require confirming adherence, excluding other causes, and potentially retreatment.

2. CURRENT TRENDS IN THE
MANAGEMENT OF ULCERS –
OPPORTUNITIES AND
CHALLENGES
By Dr Junaid Saleem
MBBS, FCPS Med
Consultant Physician
Hearts International Hospital Rawalpindi

4. Conflict of Interest Statement
 This trip and lecture is Sponsored by Getz
Pharmaceuticals
 No Other conflict of interest to declare

5. Q 1
 What is a Peptic Ulcer?
 What is an Erosion?
 What is a Recurrent Peptic Ulcer?
 What is a Refractory Peptic Ulcer?

6. Definition
 A peptic ulcer is a
defect in the gastric or
duodenal mucosa
 It may be limited to a
mucosal lesion
 Or it may extend
through the
muscularis mucosa
into the deeper layers
of the gut wall.

7. Peptic Ulcer Appearance
Maybe some people would like to have a certain amount of control; not me.
It's too much stress and includes managing everybody's egos...
handling my own is enough!
Kajol

8. Peptic Ulcer Appearance
Before the 20th century, the ulcer was not a respectable disease.
Now it’s a fashionable thing to have.
Barry Marshall

9. Peptic Ulcer Appearance
Ugliness is a point
of view;
an ulcer is
wonderful to a
pathologist..
Austin de Malley

10. Definitions
 An ulcer in the gastrointestinal (GI) tract may be
defined as a break in the lining of the mucosa, with
appreciable depth at endoscopy or histologic
evidence of involvement of the submucosa.
 An erosion is a break in the surface epithelium that
do not have perceptible depth.
 The term peptic ulcer disease is used broadly to
include ulcerations and erosions in the stomach and
duodenum

11. Definitions
 A refractory peptic ulcer is defined as an
endoscopically proven ulcer greater than 5
mm in diameter that does not heal after 12
weeks of treatment with a proton pump
inhibitor.
 A recurrent peptic ulcer is defined as an
endoscopically proven ulcer greater than 5
mm in diameter that develops following
complete ulcer healing.

12. Q 2
 What is the most common Site of Peptic
Ulceration?
I ma not the ulcer type but I am worrying about somethings
Yogi Berra

13. Common Sites
 Duodenal 50-85%
 Gastric 20-50%
 Depends on the H
pylori prevalence
(Less in 1st world
more in 3rd world)

14. Q 3
 What are the common presenting features of
PUD?
Peptic ulcers became more common in the 20th century at the same time
that these theories of Freud and other psychoanalysts became popular…..
Bbarry Marshall

15. Presenting Features
 Peptic ulcers may
present with
dyspeptic or other GI
symptoms
 OR
 it may be
asymptomatic and
present with
complications

16. Presenting Features
 Dyspepsia or Upper abdominal Pain at some
point in up to 80%
 Poorly localized
 May radiate to back
 Typically occurs 2 to 4 hours after meals, and
is relieved somewhat by food intake
 May wake the patient up from sleep after
midnight
 6 week / 6 month cycle

17. Presenting Features
 70% may be asymptomatic at the time of
Diagnosis
 Especially those with complications may have
no prior history of dyspepsia
 More common in elderly and NSAID users
 Complication may be detected by new
symptoms or increase in intensity

18. Complications
 UGI Bleed
 Hematemesis, malena, orthostatic hypotension
 Perforation
 Sudden severe upper abd pain, peritonitis, gas
under diaphragm
 Gastrocolic or gastroduodenal fistulae may form
 GOO
 early satiety, bloating, indigestion, anorexia,
nausea, vomiting, epigastric pain shortly after
eating, and weight loss

19. Q 4
 What Causes Peptic Ulcer?
To gastroenterologists, the concept of a germ causing ulcers
was like saying that the Earth is flat.
Barry Marshall

20. Causes
 Helicobacter pylori
 DU 60-90%
 GU 45-60%
 Drugs
 NSAIDS + Aspirin
 Bisphosphonates
 Steroids
 Cytotoxic drugs
 Tetracyclines, etc
 Smoking
 Alcohol
 Chronic Illnesses
 CKD (Uraemia)
 Respiratory failure
 CLD (Cirrhosis)
 Stress Ulcers
 Head Injury
(Cushing’s)
 Burns (Curling’s)
 Post surgery (eg
CABG)

21. Causes
 Acid Hypersecretors
 Gastrinoma
 Primary
Hyperparathyroidism
 Idiopathic Acid
Hypersecretion
 Blood Group O & A
 Stress
 Unusual Causes
 Crohn’s disease
 Sarcoidosis
 Lymphoma
 Ischemia
 Eosinophilic
Gastroenteritis
 Tuberculosis
 Syphilis
 Cytomegalovirus
 IgG4-related sclerosing
disease

22. Q 5
 How do you Diagnose Peptic Ulcer Disease?
Envy is the ulcer of the soul
Socrates

23. Diagnosis
 History
 Drugs – NSAIDS, Steriods, Tetracyclines, cytotoxics
etc
 Relation to meals
 Site
 Night awakening
 Cyclical pain (6weeks/6months)
 No relation to foods (despite common belief)
 Head Injury (Cushing’s Ulcer)
 Burns (Curling’s Ulcer)
 Melena / Hematochezia / Iron Def Anaemia

24. Diagnosis
 Stool RE + Occult Blood (FOB)
 Stool for HpSAg
 H pylori serology ?? IgM, IgG
 Urea Breath Test
 Blood CP – Hb, Low MCV (microcytes), Low MCH
(hypochromic RBCs)
 Serum Ferretin
 LFTs
 RFTs
 Zollinger-Ellison Syndrome (Gastrinoma)
 Gastric Carcinomas – Biopsies ??

26. Diagnosis
 Esophago-gastro-duodenoscopy (EGD), or
UGI Endoscopy – yield 90%
 Barium Meal Examination – yield 80%
 Endoscopic diagnosis of H pylori
 Rapid Urease test
 Histology
 Culture
 PCR

27. Gastric Ulcer

28. Duodenal Ulcer

29. Ulcer Radiograph

31. Q 6
 How would you treat a newly diagnosed PUD?
I had to learn to forgive. I couldn't sleep at night. I had to let go,
And let God deal with my problems and my ulcers.
Rodney King

32. Treatment of Peptic Ulcer
 Antisecretory / Acid Neutralizing Therapy
 Eradication of H pylori
 Avoid
 NSAID and Tobacco

33. Treatment of Peptic Ulcer
 Antisecretory / Acid Neutralizing Therapy
 Eradication of H pylori
 Avoid
 NSAID and Tobacco
I was hoping I was going to get an ulcer.
I was hoping to boost my research career by developing a bleeding ulcer.
Barry Marshall

34. Antisecretory Therapy
 Omeprazole
 Omeprazole with
NaHCO3
 Esomeprazole
 Pantoprazole
 Lansoprazole
 Dexlansoprazole
 Rabeprazole
 Plasma Half life
immaterial
 remarkably safe
 well-tolerated
 Drug Interaction (with
omeprazole only)
 Warfarin
 Diazepam
 Phenytoin
 Clopidogrel
PPIs Effects & SEs

35. Antisecretory Therapy
 Cimetidine
 Ranitidine
 Famotidine
 Nizatidine
 Well Absorbed
 Well tolerated
 Weak Anti androgenic
effect – gynaecomastia
 Myelosuppression
 Tolerance is common
 Drug Interactions –
Hepatic P-450(CYP)
inhibitors (Cimetidine and
ranitidine) – theophylline,
phenytoin, lignocaine,
quinidine, and warfarin
H2RAs SEs

36. Acid Neutralizing
 1 gm QID
 DU healing = H2RA
 FDA +
 GU healing +
 FDA -
 Binds to + charged
exposed proteins in
ulcer base
 No systemic
absorption
 Not enough
evidence in CKD –
avoid
 Can bind to drugs
 Warfarin
 Phenytoin
Sucralfate SEs

37. Acid Neutralizing
 Magnesium,
Aluminum, and
Calcium salts of
Carbonates and
Hydroxide
 Healing 67%
 20-30 ml 1 and 3
hours after meals,
and bedtime
 Constipation – Mg
 Diarrhoea – Al / Ca
 Volume, Taste
 Bone effects
 Accumulation in
CKD
Antacids SEs

38. Others
 Misoprostol
 30% have diarrhoea
 May cause abortion
 Subcitrate /
Subsalicylate
 Weak Anti ulcers by
themselves
 Help in H pylori
eradication
Prostaglandin E Agonists Bismuth

39. Treatment of Peptic Ulcer
 Antisecretory / Acid Neutralizing Therapy
 Eradication of H pylori
 Avoid
 NSAID and Tobacco
I hate putting negative energy out into the world.
But it's either inside or out.
I mean, it's either get an ulcer or have a fight.
Sharon van Etten

40. Helicobacter pylori eradication
Triple therapy 10 – 14 days
Antibiotic 1 Antibiotic 2 Acid suppression
Clarithromicin
500 mg BD
(or Metronidazole*
500 mg TID if intolerant)
*Tinidazole 500 mg BD
or Furazolidine 100 mg
TID / QID can be
substituted for
Metronidazole
Amoxicillin
1 Gm BD
(or Metronidazole
500 mg TID if SEs)
Omeprazole
20 mg BD
Rabeprazole
20 mg BD
Lansoprazole
30 mg BD
Pantoprazole
40 mg BD
Ranitidine
150 mg BD
Cimetidine
400 mg BD

41. Helicobacter pylori eradication
Alternative Triple therapy 7 – 14 days
Antibiotic 1 Antibiotic 2 Acid suppression
Levofloxacin
250 mg BD /
Ciprofloxacin
500 mg BD
or
Rifabutin
300 mg OD
or
Tetracycline
500 mg QID
Amoxicillin
1 Gm BD
PPI BD

42. Helicobacter pylori eradication
Bismuth Containing Quadruple therapy 10 – 14 days
Antibiotic 1 Antibiotic 2 Acid suppression Bismuth
Tetracycline
250 mg QID
Metronidazole
500 mgBD
Or
Tinidazole
500 mg BD
PPI BD Bismuth
Subsalicylate 120
mg QID

43. Helicobacter pylori eradication
Non Bismuth containing Quadruple therapy 10 - 14 days
Antibiotic 1 Antibiotic 2 Antibiotic 3 Acid suppression
Clarithromicin
500 mg BD
Amoxicillin
1 Gm BD
Metrponidazole
500 mg BD
PPI BD

44. Helicobacter pylori eradication
Non Bismuth containing Quadruple therapy SEQUENTIAL
1st Week 2nd Week Acid suppression for 2
weeks continued
Amoxicillin
1 Gm BD
Clarithromicin
500 mg BD
+
Metronidazole
500 mg BD
PPI BD

45. Helicobacter pylori eradication
Non Bismuth containing Quadruple therapy HYBRID
1st Week 2nd Week Acid suppression for 2
weeks continued
Amoxicillin
1 Gm BD
Amoxicillin
1 Gm BD
+
Clarithromicin
500 mg BD
+
Metronidazole
500 mg BD
PPI BD

46. Helicobacter pylori eradication
Non Bismuth containing Quadruple therapy REVERSE HYBRID
1st Week 2nd Week Acid suppression for 2
weeks continued
Amoxicillin
1 Gm BD
+
Clarithromicin
500 mg BD
+
Metronidazole
500 mg BD
Amoxicillin
1 Gm BD
PPI BD

47. Q 7
 How would you confirm eradication of H
pylori?
If you spend your life competing with
business men, what do you have?
A bank account and ulcers!
Marilyn Monroe

48. Confirmation of Eradication of H pylori
 Preferably by the same method that was used
to initially diagnose the infection.
 Urea Breath Test - NEG in 4 wks
 HpSAg Test – NEG in 4 wks
 Biopsy }
 Culture } needs re-endoscopy - difficult
 Urease }
 IgM Abs should decline in 6 months??
 IgG Abs will remain positive for life

49. Q 8
 How would you treat a Recurrent / Refractory
Peptic Ulcer?
Despite the disreputable company it
keeps, bismuth is harmless.
Sam Kean

50. Refractory Ulcer treatment
 Confirm adherence
 R/O NSAID use
 R/O other less common causes like Sarcoid, TB,
Crohn’s, Eosinophilic Gastritis, Ischemia and
Cancers etc
 Biopsy preferred to get a C/S and R/O other
diseases – treat accordingly
 Re-Treat with diff antibiotics
 Longer treatment would be needed with PPI
(maybe 12 weeks and more)

51. American Gastroenterological
Association guideline for the
management of dyspepsia.
This is the current management
approach for patients with
suspected peptic ulcer disease.
(Adapted from Talley NJ.
American Gastroenterological
Association medical position
statement: evaluation of
dyspepsia. Gastroenterology
2005; 129:1753-5.)

52. Q 9
 Dietary Advise?
You don't get ulcers from what you eat.
You get them from what's eating you.
Vicki Baum

53. Causes / Aggravating Factors
 Foods
 Vit A
 Fiber
 Irritants
 Black & red pepper
 Chili powder
 Spices
 Delayed Gastric
Emtying
 Fatty and fried foods
 Increased Acid
Production
 Tea & Coffee
 Cocoa
 Chocolate
 Cola beverages &
carbonated drinks
 Citrus fruits and
juices
 Tomato products
 Peppermint
 Wheat & Rice

54. Q 10
 What are the Alarm features in PUD?
The poor think they will be happy when they become rich.
The rich think they will be happy when they are rid of their ulcers.
Anthony de Melo

55. Alarm Features

56. Q 11
 What differential diagnoses would you
consider?
I Have an ulcer – its IQ is 185
Paul Linde

57. Differential Diagnoses
 Dyspepsia
 Functional, including IBS
 Drug induced
 Non specific
 Celiac disease
 Gastric malignancy
 Chronic pancreatitis
 Biliary disease
 Stones, obstruction etc
 Biliary Dyskinesia “I don’t get an ulcer.
I give them”
Ed Koch