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