Peptic ulcer 🌋
Definition
Ulceration in the GI tract due to acid from stomach
Type
duodenal
gastric
esophageal
Meckel Diverticulum
Pathophysiology
Disease: H. pylori
Corkscrew shape of bacterium allows it to burrow into epithelium
high acid content causes gastric metaplasia - facilitates growth of H. pylori
colonisation leads to even more metaplasia (vicious cycle)
breaks down urea via urease
ammonia and bicarbonate create neutral environment for bacteria to grow
Drug
NSAIDs
Inhibit prostaglandin synthesis - prevents protective effects on gastric epithelium
Corticosteroids
lower cell renewal process - susceptible to damage
Coffee, alcohol, smoking
Impact
Damage to esophagus - haematemesis
Perforation into peritoneal cavity
Penetration into adjacent site (pain at epigastric area spreading to the entire abdomen)
Gastric outlet obstruction
Signs and Sx
Burning pain
From navel up to breastbone
Occurs at night and on empty stomach
Relief when taking any acid-buffering food/medication
Vomiting of blood
Black/tarry stools
NV, Anorexia
Weight loss
Pharmacological Approach
H2RA
cimetidine, ranitidine, nizatidine, famotidine
Reduce inflammation, healing rate within 6-8 weeks
cimetidine - multiple drug interactions due to inhibition of CYP450 enzymes
Impair absorption of basic drugs
Dizziness, diarrhoea, thrombocytopenia, confusion
PPI
Reduces acid secretion
Omeprazole, lansoprazole, pantoprazole
Need to be taken before meal
Adjust in hepatic impairment
Common side effect: abdominal pain, nausea
DDI
Omeprazole
Inhibits CYP2C19 - higher levels of warfarin (increased PT), phenytoin
Lansoprazole
Induces CYP1A, induces theophylline metabolism
Increases bioavailabiltiy of digoxin and nifedipine, decrease absorption of ketoconazole and itraconazole
Sucralfate
Creates protective layer around ulcer
Take before food to avoid coating other proteins
Constipation, nausea, dry mouth
Bismuth salicylate
Increase PG production, gastroprotective effect, effective against H pylori
SE: Salicylism: headache, dizziness, abdominal pain; blackened stools
Regimen
1st-line
Amoxicillin 1g BD/metronidazole 500mg BD
Clarithromycin 500mg BD
PPI: omeprazole (20mg OD)
2nd line:bismuth combination
Bismuth 500mg
Metronidazole 250-500mg
Amoxicillin500mg BD/clarithromycin 250-500mg BD
PPI
Maintenance and Relapse
Relapse
Sx persists after 8-12 weeks
Higher dose of PPI
Maintenance
When recurrence is likely, history of bleeding, NSAIDs continuous treatment
Low dose PPI, H2RA for DU
Higher dose of PPI for GU
For aspirin
Std dose PPI> high dose H2RA