10. Inci ence an i emi logy
Peptic ulcers are the most common source of upper GI
bleeding accounting up to -so% of cases
z most common causes of PUD: Helicobacter py/ori
infection and NSAID use.
As the prevalence of H. pylori infection decreases and
NSAID use increases, the relative contribution of each
factor to the incidence of PUD will change.
References: Harrison's Principles of Internal Medicine 17**edition
Wong, et al. Changing trends in peptic ulcer prRvalence in a tertiary carE' setting in the Philippines: A seven-
year study. Journal of Gastroenterology and Hepatology, Vol 20, Number 4, April 200s: s2g-s32(5)
11. inci ence an i emi i
DUODENAL ULCERS
• 6-i5% of the Western population
• Incidence declined steadily from 1960 tO•9 o and has
remained stable since then >so% over visits have
decreased over the past 3o years
• The declining global prevalence is due to declining
prevalence of Helicobacter pylori infections
• Eradication of H. pylori has greatly reduced the
recurrence rates after initial therapy
12. GASTRIC ULCERS
• Tend to occur later in life than duodenal lesions, with
peak incidence reported in the 6th decade
• More than half of GUs occur in males
• Less common than duodenal ulcers, perhaps due to
higher likelihood of Gus being silent and presenting
only after a complication develops
13. inicai anisfestati n
Abdominal pain
• Burning or gnawing discomfort
at epigatrium
• Ill-defined, aching sensation,
hunger pain
• Occurs 9omins 3 hrs after
meal, empty stomach, early
morning
• Relieved by foods or antacids
14. Nausea, vomiting, weight loss
Epigastric tenderness
• Right of midline (zo%)
Other posible manifestation
- GI bleeding
• Bloody or dark tarry stools
• Coffee ground emesis
• Chest pain
• Fatigue
15. Perforation
• Sudden, severe, generalized abdominal pain
• Tender, boardlike abdomen
Peptic ulcers
may lead to
bleeding or
perforation,
emergency
Situations
16.
17. Barium Studies
Still commonly used as a first test for documenting an
ulcer
' 8o% sensitivity : single contrast barium study
9o% sensitivity: double contrast barium study
Sensitivity is low for small ulcers (<o•s cm)
- Duodenal ulcers appear as a well demarcated crater
most oñen seen at the bulb
- Gasti ic ulcers may either be benign or malignant
18. Bari m St ies
Benign gastric ulcer appears as a discrete crater with
radiating mucosal folds originating from the mucosal
margin
Ulcers >3 cm are more ohen malignant
Radiographic studies that show a gasti ic ulcer must be
followed by endoscopy and biopsy.
F.inci, et. al. Harrison's Principles of Internal Metlicine, •7 th ed.
19. Endoscopy
Most sensitive and specific
' Direct visualization of the mucosa
' Photographic documentation of the defect
' Tissue biopsy to rule out malignancy or H. pylori.
' Helpful in identifying lesions too small to detect by
radiographic examination, evaluation of atypical
radiographic abnormalities, or to determine if an ulcer
is a source of blood loss
F.inci, ct. a1. Harrison's Principles of Internal Medicine, •7 th ed.
20. Detecti n pylori
• NON-INVASIVE
• Serology
• Detection of antibodies in the serum
• Urea Breath Test
• Simple, rapid, early follow up
• Stool antigen
• Sensitive, specific, and inexpensive
Fauci, et. al. Harrison's Principles of Internal Medicine, i7th ed.
21. Detecti n pylori
• INVASIVE (Endoscopy/Biopsyrequired)
• Rapid urease
• Simple, false negative with recent useof PPIs, antibiotics, or
bismuth compounds
• Histology
• Provides histologic information
• Culture
• Time-consuming, expensive
Fauci, et. al. Harrison's Principles of Internal Medicine, i2 th ed.
24. Antaci s
Rarely used as a primary therapeutic agents but are
instead used for symptomatic relief
' Mixture of aluiviiiauivihydroxide and iviagiaesiriiii
hyclloxicle
* Eg. Maalox, Mylanta
F.inci, ct. a1. Harrison's Principles of Internal M€•dicine, •7 th ed.
25. H2 Receptor Antagonists
Inhibit basal and stimulated acid secretion
Oñen used for treatment of active ulcers (4-6 weelxs)
in combination with an antibiotic directed at
eradicating H. py/ori.
• Eg. Cimetidine, Ranitidine, Famotidine, Nizatidine
F.inci, ct. a1. Harrison's Principles of Internal Medicine, •7 th ed.
26. roton m in i itors
Substituted benzimidazole derivatives that covalently
bind and irreversibly inhibit H+IC+-ATPase
' Eg. Omeprazole, Esomeprazole, Lansoprazole,
Rabeprazole, Pantoprazole
F.inci, et. al. Harrison's Principles of Internal Medicine •7 th ed.
27. Cyto rotective Agents
Sucralfate
• Insoluble in water
• Viscous paste within the stomach and duodenum, binding
primarily tOsites of active ulceration
Bismuth-containing compounds
• Ulcer coating; prevention of further pepsin/HCI-induced
damage; bind’ing of pepsin; and stimulation of PGs,
bicarbonate, and mucous secretion
: Prostaglandin Analogues
• Enhancement of mucosal defense and repair
• Eg. Misoprostol
F.inci, et. al. Harrison's Principles of Internal Medicine. *7 th ed.
28. TH RAPY FO pylori
Eradication of H. pylori is the primary goal
TRIPLE THERAPY
i. Bismuth subsalicylate plus
Metronidazole plus
Tetracycline
z tabs qid
zoo mg qid
soo mg qid
4oo mg bid
too mg bid
soo mg bid
zo mg bid (3o mg bid)
so or too mg bid
3oo mg bid
i g bid
z. Ranitidine bismuth citrate plus
Tetracycline plus
Clarithromycin or Metronidazole
3. Omeprazole (lansoprazole)plus
Clarithromycin plus
Metronidazole or
Amoxicillin
