Pud Final 5

Peptic Ulcer Disease
Presented by:
Dr.Al-Muzahid Shuvo
FCPS part-2 Trainee
SZMCH,Bogura
Outline
• Introduction
• Pathophysiology
• Etiology/Risk factor
• Clinical features
• Investigation
• Complications
• Management
• References.
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.
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.
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

Pathophysiology
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

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 of PUD.
Other presentations:
• anorexia ,nausea
• early satiety after meals
• Anemia from occult blood loss
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.
Endoscopic Findings
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
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
H.pylori eradication is not
indicated in - GERD
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
MANAGEMENT :
• Life style modification
• Acid suppressing drug therapy
• H. pylori eradication therapy
• Surgery
LIFE STYLE MODIFICATION :
• Discontinue NSAID
• Smoking cessation
• Alcohol cessation
• Reduce stress
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
MoA of anti-ulcerant Drugs
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
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 ).
THERAPY OF NSAID-RELATED GASTRIC
OR DUODENAL INJURY
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.
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 sure that eradication has
been successful.
Surgical treatment
Indications:
• Failure of medical treatment.

• Development of complications
• High level of gastric secretion and combined duodenal
and gastric ulcer.
Types of Surgical Procedures
• Gastroenterostomy
• Vagotomy
• Gastrectomy - Billroth -1, Billroth-2
Post-op Complications :
• Dumping syndrome
• Bile reflux gastropathy
• Diarrheoa and Malabsorption
• Weight loss
• Anemia
• Osteoporosis and osteomalacia
• Gastric cancer
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
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/
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 ).
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.
st
•Harrison principle of medicine 21 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
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Peptic Ulcer Disease

Peptic Ulcer is a lesion in the lining (mucosa) of the

• Drugs : NSAID, Steroid, aspirin

• Stress: Physiological ,Burn , CVD

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

• Recurrent upper abdominal pain ( burning) , localise to

• Occasionally vomiting in 40% case.

[N.B] If a patient points with a single finger to the epigastrium

• Older pt: require endoscopic dx & exclusion of cancer. All

• All patient e alarmed symptoms should undergo

• Narrowing and obstruction (pyloric)

• Acid suppressing drug therapy

• H. pylori eradication therapy

• H2-Receptor Antagonists- Cimetidine, Famotidine, Nizatidine

• Mucosal protective agent :

H. pylori Eradication Therapy:

•Triple therapy: for atleast 7 days, can extend to 10-14 days.

❖ Standard Bismuth Quadruple therapy - now mainstry threapy

• Prolong therapy with PPI after Triple therpay is not

• After completion of course of H.Pylori continue rx with

• Patient with risk of bleeding or those with complication

• Failure of medical treatment.

19 studies including 7023 participants were analyzed:

• H. pylori is the most common cause of PUD and is a risk

• H Pylori eradication reduces risk of disease recurrence.

• Optimum treatment regimens are 14d multidrug with

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