Introduction.......Aetiology.............Pathophysiology.................. Clinical Features........ Investigation..................................Management.......................

1. Peptic Ulcer Disease
Presented
by:
Dr.Al-Muzahid Shuvo
FCPS part-2 Trainee
SZMCH,Bogura

2. Outline
• Introduction
• Pathophysiology
• Etiology/Risk factor
• Clinical features
• Investigation
• Complications
• Management
• References.

3. Definition
Peptic Ulcer is a lesion in the lining (mucosa) of the
digestive tract, typically in the stomach or duodenum,
caused by the digestive action of pepsin and stomach
acid.

4. Common site of PUD :
• First part of duodenum
• Stomach
• Lower oesophagus
• Within the margin of gastro-jejunostomy
• Throughout GIT in ZES
• Within or adjacent to ileal Meckels
diverticulum that contains gastric ectopic
tissue.

5. ETIOLOGY/ RISK FACTORS :
• H. Pylori infection
- 90% have this bacterium
- Passed from person to person (fecal-oral route or oro-
oral route)
• Drugs : NSAID, Steroid, aspirin
• Smoking, Alcohol
• Stress: Physiological ,Burn , CVD

6. Pathophysiolog
y
Depletion of antral D cell Somatostain
Increased gastrin release from G cell
Increased acid secretion
Increased acid load in duodenum leads to gastric
metaplasia
Further inflammation & eventual ulceration

8. Clinical features
:
• PUD is chronic condition e spontaneous relapse and
remission.
• Recurrent upper abdominal pain ( burning) , localise to
epigastrium,relationship to food and episodic
occurrence.
• Occasionally vomiting in 40% case.
[N.B] If a patient points with a single finger to the
epigastrium as the site of pain,this is strongly suggestive

9. Other
presentations:
• anorexia ,nausea
• early satiety after meals
• Anemia from occult blood loss

11. Investigation of suspected
PUD :
• PT under 55 years of age : with typical symptoms of
PUD who test positive for H.pylori,can start
eradication therapy without further inv.
• Older pt: require endoscopic dx & exclusion of cancer.
All gastric cancer must be biopsied to exclude an
underlying malignancy & should be followed up
endoscopically until healing was taken place.
• All patient e alarmed symptoms should undergo
endoscopy.

12. Endoscopic Findings

13. Method for detection of H.Pylori
Non Invasive :
1. Serolgy
2. Urea Breath test : as screening test
3. Stool antigen test
Invasive :
1. Histology
2. Rapid urease test
3. Microbiological culture

14. Indication for H.pylori test :
A. Active or past history of PUD
B. Extranodal marginal zone of lymphoma of MALT
C. Previous endoscopic resection for early gastric ca.
D. Dyspepsia
E. long term NSAID or Low dose aspirin users
F. Extragastric disorder ----- 1. ITP 2.IDA
G. Unexplained Vit B12 deficiency

15. H.pylori eradication is not
indicated in - GERD

16. Complications of Peptic Ulcers
• Hemorrhage
Blood vessels damaged as ulcer erodes into the muscles of stomach
or duodenal wall
- Coffee ground vomitus or occult blood in tarry stools
• Perforation
- An ulcer can erode through the entire wall
- Bacteria and partially digested food spill into peritoneum=peritonitis
• Narrowing and obstruction (pyloric)
- Swelling and scarring can cause obstruction of food leaving
stomach=repeated vomiting

17. MANAGEMENT
:
• Life style modification
• Acid suppressing drug therapy
• H. pylori eradication therapy
• Surgery

18. LIFE STYLE MODIFICATION
:
• Discontinue NSAID
• Smoking cessation
• Alcohol cessation
• Reduce stress

19. Drugs used in PUD:
• Proton Pump Inhibitors- Omeprazole,Lansoprazole,
dexlansoprazole, Esomeprazole.
• H2-Receptor Antagonists- Cimetidine, Famotidine, Nizatidine
• Antacids-
• Mucosal protective agent :
- Sucralfate
- Prostaglandin analogue-Misoprostol
-Bismth containing compound – Bismuth
subsalicylate

20. MoA of anti-ulcerant Drugs

21. Drugs used in
PUD(cont..
H. pylori Eradication Therapy:
•Triple therapy: for atleast 7 days, can extend to 10-14 days.
Drugs : Proton pump inhibitor + 2 Antibiotics (Metronidazole ,
Amoxicillin or Clarithromycin)
Standard Bismuth Quadruple therapy - now mainstry
threapy
-Ppi orally twice daily
-Bismuth subsalicylate (300mg) or subcitrate (120-
400mg) . orally 4 times a day.
-Tetracyclin 500mg 4 times a day orally-
-Metronidazole 500mg 3 times daily

23. Salvage Therapies for H.
pylori Infection
 If first line therapy fails – Bismuth quadraple therapy
now used mainly .
 Sequential courses of therapy are also used in such
case ( 5 days of PPI & Amoxicillin followed by a 5 day
period of PPI ,Clarithromycin & Tinidazole ).

25. THERAPY OF NSAID-RELATED
GASTRIC OR DUODENAL INJURY

27. How long ppi should given after successful
triple/quadraple therapy ?
• Prolong therapy with PPI after Triple therpay is not
necessary for ulcer healing in most of the cases.
• After completion of course of H.Pylori continue rx with
oral ppi once daily for 4-6 wk if ulcer is large (>1cm) or
complicated.

28. How or when needs follow up
investigation ?
• The effectiveness of treatment for uncomplicated
ulcer should be assessed symptomatically. If
symptoms persist,breath or stool testing should be
performed .
• Patient with risk of bleeding or those with
complication such as haemorrhage or perforation
should always have a Urea breath test or stool test
for H.pylori 6 weeks after the end of treatment to be

29. Surgical treatment
Indications:
• Failure of medical treatment.
• Development of complications
• High level of gastric secretion and combined
duodenal and gastric ulcer.

30. Types of Surgical
Procedures
• Gastroenterostomy
• Vagotomy
• Gastrectomy - Billroth -1, Billroth-2

32. Post-op Complications :
• Dumping syndrome
• Bile reflux gastropathy
• Diarrheoa and Malabsorption
• Weight loss
• Anemia
• Osteoporosis and osteomalacia
• Gastric cancer

33. Refractory peptic ulcers
• Defined as ulcers that do not heal completely after 8 to
12 weeks of standard anti-secretory drug treatment
• lack of adherence to treatment
• Persistence of H. pylori infection
• Use or abuse of high doses NSAID
• Zollinger-Ellison syndrome
• Gastric acid hypersecretion, rapid PPI metabolization,
ischemia, chemo-radiotherapy, immune diseases, more
rarely to other drugs or be fully idiopathic.
• High-dose PPI or the new potassium competitive acid
blocker or the combination of PPIs with misoprostol can
be recommended in these cases

34. PCAB versus PPI in treating gastric acid-related diseases
19 studies including 7023 participants were analyzed:
• Vonoprazan is superior to PPI in first-line H. pylori
eradication and erosive esophagitis
• Non-inferior in other gastric acid-related diseases-There
were no differences in the improvement of GERD
symptoms and healing of gastric and duodenal ulcers
between PCAB and PPI.
• https://pubmed.ncbi.nlm.nih.gov/36181401/

35. Summary
• H. pylori is the most common cause of PUD and is a
risk factor for gastric cancer.
• H Pylori eradication reduces risk of disease
recurrence.
• Optimum treatment regimens are 14d multidrug with
antibiotics and acid suppressants(Triple therapy ).

36. REFERENCES
http://emedicine.medscape.com/article/181753-overview#/showall.
Retrieved 28* Jan, 2016
Fendrick M, Forsch R etal. Peptic Ulcer Disease Guidleines for Clinical
Care.
•Harrison principle of medicine 21st edition
•Kumar and clark internal medicine 10th edition
•Davidson medicine and principle of practice 24th edition
and treatment. Postgrad Med 2005;117(6): 17-22, 46

37. Thank you