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Gastric and Duodenal Peptic Ulcer

Peptic ulcer is a break in the gastric or duodenal mucosa that arises when the normal mucosal defensive factors are impaired or are overwhelmed by aggressive luminal factors such as acid and pepsin. This imbalance results in any degree of gastrointestinal mucosal irritation, inflammation or ulceration. * Patho-physiology: Aggressive Factors a- HCl. b- Pepsin. c- Helicobacter Pylori. d- Bile salts. Defense Mechanisms a- Prostaglandins. b- Mucus. c- Bicarbonates. d- Blood supply. e- Mucosal regeneration.
Peptic Ulcer Disease

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* Clinical Features: 1- Symptoms & Signs: a- Epigastric pain & tenderness. b- Anorexia, Nausea & Vomiting. c- Hemorrhage. 2- Endoscopy. 3- Presence of H. pylori : Endoscopic biopsy, serological test & Urea breath test. * Goals of Therapy: 1- Pain Relief. 2- Promotion of healing. 3- Prevention of recurrence. 4- Preventing ulcer complications e.g. bleeding, perforation.

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2. B) Antisecretory Drugs (Reduction of Acid Secretion): 1.Prostaglandins: Misoprostol.Sucralfate. 3. C) Mucosal Protectives (Enhancement of Mucosal Resistance): 1.Gastrin Antagonists: Proglumide. 4.Antimuscarinic Drugs: Pirenzepine. 4.Prostaglandins : Misoprostol. 2. 51 .Carbenoxolone.Proton Pump Inhibitor (H+/K+ ATPase Inhibitors): Omeprazole.* Drug Therapy: A) Antacids (Neutralization of secreted HCl): . 5.Aluminum Hydroxide + Magnesium hydroxide or Trisilicate. 3.Colloidal bismuth.H2-Receptor Blockers: Cimetidine.

D) Eradication of H.Metronidazole.Tetracycline.Bismuth compounds. pylori: 1. 2. E) Other Drugs: 1. 2. 4.Tricyclic Antidepressants → Psychic effects + Anti-cholinergic + H2block.Sedatives or Tranquillizers e. 5. 3.Estrogen on Males → But feminization 52 . Diazepam → # Psychic effect on acid secretion.Clarithromycin. 3.Amoxicillin.g.

Mental  diazepam 2. Milk contains: a.Management of peptic ulcer: * General Measures I.Fats → Enterogastrone hormone → ↓ Acidity and motility. II. ii.Physical  only in presence of complications.Colloids → Demulcent effect on mucosa & adsorption of HCl and pepsin. b.However Excess milk → Excess Ca & Proteins → Gastrin → Rebound hyperacidity 53 .Diet: 1.Milk in reasonable amounts is suitable.Amphoteric → Chemical neutralization of HCl. 2.Small frequent light meals.Rest: 1.Proteins → i. c.

54 . vinegar.Chewing gum.Beverages : Xanthines (Coffee & tea). d. fried meat & meat extract.Smoking . c. Carbonated & Alcoholic. spicy foods.Avoid: a.Heavy meals.3. b.

2.Parasympathomimetics. ↓ PGs & Bleeding. 9. 6. b. → Gastric secretions & conc. > 40% → Irritation.Histamine. Theophylline → Irritation.III. Paracetamol is allowed. Histamine like & Histamine releasers. Aspirin → Irritation. Glucocorticoids & ACTH.Stomachics & Digestatnts.Drugs to be avoided: 1-Anti-Inflammatory drugs : a.Alcohol : Up to 10% Conc.Tobacco → Irritation and ganglion stimulation (Nicotine SD). 55 .Tolazoline & Phentolamine → Histamine like. 5.g.SAID e. 7.Reserpine.NSAID e.Xanthines : Caffeine → Gastric secretions.KCl oral preparation.g. 10. 4. 8. 3.

Clarithromycin: 500 mg twice per day orally + 2. a.Active ulcer + H pylori infection  Anti-microbials + Anti-secretory 1.For eradication of H. 56 .First Line: PPI-based triple therapies for H pylori are considered the first-line therapies for the treatment of H pylori.Amoxicillin: 1 gm twice per day orally OR Metronidazole: 500 mg twice per day orally (for penicillin-allergic patients).Medical Treatment * Drugs A.2 weeks.pylori: Double antimicrobial therapy for 1 . 1.

 Lansoprazole (Prevacid): 30 mg orally twice/day. 57 . OR in patients who can NOT tolerate proton pump inhibitors 2. or  Rabeprazole (Aciphex): 20 mg orally twice/day.  Omeprazole (Prilosec): 20 mg orally twice/day.b.H2-blocker for 6-8 weeks • Cimetidine 800 mg at bed time or 400 mg bid. • Famotidine 40 mg at bed time or 20 mg bid.Anti-secretary Drug: 1. then continue once per day for 4.Proton pump inhibitor Twice per day orally for two weeks. or  Esomeprazole (Nexium): 40 mg orally /day.8 weeks. • Ranitidine 300 mg at bed time or 150 mg bid. • Nizatidine 300 mg at bed time or 150 mg bid.

Bismuth 525 mg orally four times /day and .Active ulcer with No H pylori infection Either : Proton Pump Inhibitor (Omeprazole) OR H2 blockers (Ranitidine) For 4 weeks in duodenal ulcer and 8 weeks in gastric ulcer.Metronidazole 500 mg orally four times /day and .Tetracycline 500 mg orally four times /day B. 58 . The treatment includes the following drugs: .PPI orally four times /day and .NB) Quadruple therapies for H pylori infection are generally reserved for patients who have failed a course of treatment and are administered for 14 days.

OR . For patients with a known history of ulcer. the lowest possible dose and duration of the NSAID and co-therapy with a PPI or misoprostol (analog of PGE1) are recommended.g.H2 -Blockers: Half dose. Ranitidine (150mg).Prevention of relapse: Therapy given for 6 months.g. Either: . Omeprazole 20 mg 30 minutes before breakfast. C.Proton Pump Inhibitor e. 59 .NB) Active ulcers associated with NSAID use are treated with an appropriate course of PPI therapy and the cessation of NSAIDs. and in whom NSAID use is unavoidable.

... 5.... 3. 2....Treatment of acute hemorrhage complicating an ulcer: 1..After 48 hours → treatment as active stage...D.General Measures: Bed rest + Fresh blood transfusion + Oxygen. E..After control of bleeding give milk 50 – 100 ml by gastric drip + antacid.. 4...Local injection of adrenaline.Gastric lavage with ice cold saline.- 60 . .Surgery: in severe hemorrhage or perforation.

* Sample of Prescriptions: 1.Eradication Therapy: ℞ Omeprazole 20 mg Capsules ‫كبسولة مرتين يوميا لمدة أسبوع‬ ℞ Clarithromycin 500 mg Tablets ‫قرص مرتين يوميا لمدة أسبوع‬ ℞ Amoxicillin 1000 mg Tablets ‫قرص مرتين يوميا لمدة أسبوع‬ 61 .

2.Eradication Therapy in a Patient Allergic to Pednicillins: ℞ Omeprazole 20 mg Capsules ‫كبسولة مرتين يوميا لمدة أسبوع‬ ℞ Clarithromycin 500 mg Tablets ‫قرص مرتين يوميا لمدة أسبوع‬ ℞ Metronidazole 400 mg Tablets ‫قرص مرتين يوميا لمدة أسبوع‬ 62 .

Use in peptic ulcer: i.Beneficial effects in peptic ulcer. iii.Adverse effects. 5. 63 .Mechanism of action. ii.Patient education and counseling. iv.Compelling indications. c.* Points for Discussion: For EVERY drug or group of drugs used in treatment of peptic ulcer.Inhibition of recurrence.Eradication of H. 2. kindly discuss the following points: 1.Compelling contraindications.Drug interactions. 3.Role of this drug / group in peptic ulcer: a.Contraindications. pylori. 4. b.

c.Shake the suspension well. 7.Take high fiber diet. within 1 – 2 hours of antacid administration. 3.Bismuth: The mouth.Aluminum may produce: 64 .If constipation especially with calcium and aluminum salts: a. b.Drink 8 -13 glasses of water (240 ml). 9.Do not use other drugs such as H-2 blockers. tongue and stool may become blackened and that this is a temporary effect. misoprostol and suceralfate. 10. 2.Antacids contain hidden sodium and potassium. 3.Antacid therapy normally makes stools appear speckled or whitish. 8. drink 175 – 240 ml water after swallowing the suspension.Combine with a magnesium containing antacid.Separate the administration of ant acids and enteric coated drugs by 1 hour to avoid premature release of enteric coated drugs in the stomach.* Sample of Patient Education and Counseling: A) Antacids: 1.

g. B) Others: 1. Ask the patient's relative to monitor his cognitive functions and memorization. b.H-2 Blockers e.Be aware of bradycardia.a.Do not use an antacid within 1 hour of H-2 blocker. d. b. decrease h-2 blocker absorption.Avoid any activity that requires alertness. anorexia and muscle weakness. 65 .Take seizure precautions with cimetidine.Hyperaluminemia: Osteomalacia and dementia. c. e.Sexual dysfunction may occur with the intake of cimetidine.Hypophosphatemia manifested by malaise. Cimetidine: a.

. . b.Omeprazole: a. c. 3.Use effective contraceptive methods.Not to perform any activity that requires alertness.If pregnancy is suspected. b.May produce diarrhea. 66 .Obtain a serum pregnancy test 2 weeks before beginning therapy.2.Inhibits the metabolism of other drugs such as diazepam. stop misoprostol immediately.Omeprazole and lasoprazole interferes with absorption of ampicillin.Notify the physician if planning to become pregnant.Misoprostol: a. . . ketoconazole and iron salts. phenytoin and warfarin. c.Taken with food.May produce miscarriage.

b.2. .May produce nausea and metallic taste.Sucralfate: a.should be administered: . 67 .One hour before meals and at bed time.2 hours before or after all other medications.

d.Drugs that should be avoided: a. c. b. e. e.Sucralfate.To eradicate helicobacter pylori infection the following drugs are given: a.Excessive intake of milk.Omeprazole. d.Small frequent meals. 3. 2. d. c.Case No 1: A 42 year old man presented with a 5 weeks history of epigastric pain and endoscopy revealed a duodenal ulcer and tests were positive for helicobacter pylori.Diclofenac sodium.Avoid spices and stomachics.Corticosteroids.Mental rest.Paracetamol b.General measures that the patient should follow: a.Smoke at ease. 1. d.Metronidazole.Clarithromycin 68 .KCl.Amoxicillin. c. b.Misoprostol.

b.150 mg per day orally. 7.150 mg per day IM.Blocking H1 receptors.Which drug of the ones chosen in question 3 decreases gastric acid secretion: (a b c d e) 5. b.Aspirin.Blocking M1 receptors.20 mg per day orally.400 mg per day orally. d.Famotidine.Blocking gastrin receptors. 69 . c.4. e.The following may be used to prevent the recurrence of the duodenal ulcer: a. c.Reserpine. c.Blocking H2 receptors. b.Blocking 5HT3 receptors. d.Prednisolone. d.300 mg per day orally. 6. e.The drug chosen in question 5 acts by: a.The dose of the selected drug in Q-5 is: a.Bethanechol. e.

d.b. d.Prednisolone.a. 9.Rifampicin. 6. d.b.Stimulates M1 receptors.Stimulates H2 receptors. 9. 3.a. 2.b.Diclofenac b. e. 4. d. KEY: 1.8. d. 7.stimulates gastrine receptors.Which drug is used to prevent aspirin induced peptic ulcer: a.Inhibits H K ATPase enzyme. c.Analogue of PGE1. d.a.Misoprostol. e.c. d. 5. c. c. c. 8. b. 70 .c.The drug in question 8 is: a.Amoxicillin.