PUD-Peptic ulcer disease presentation slides

Introduction.......Aetiology.............Pathophysiology.................. Clinical Features........ Investigation..................................Management.......................

1. Peptic Ulcer Disease Presented by: Dr. Al- Muzahid Shuvo FCPS part-2 Trainee SZMCH,Bogura

2. Outline Introduction Pathophysiology Etiology/Risk factor Clinical features Investigation Complications Management References.

3. 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.

4. 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.

5. 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

6. 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

7. 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.

8. Other presentations : anorexia ,nausea early satiety after meals Anemia from occult blood loss

9. 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.

10. Endoscopic Findings

11. Method for detection of H.Pylori Non Invasive : Serolgy Urea Breath test : as screening test Stool antigen test Invasive : Histology Rapid urease test Microbiological culture

12. Indication for H.pylori test : Active or past history of PUD Extranodal marginal zone of lymphoma of MALT Previous endoscopic resection for early gastric ca. Dyspepsia long term NSAID or Low dose aspirin users Extragastric disorder ----- 1. ITP 2.IDA Unexplained Vit B12 deficiency

13. H.pylori eradication is not indicated in - GERD

14. 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

15. MANAGEMENT : L ife style modification • Acid suppressing drug therapy • H. pylori eradication therapy • Surgery

16. LIFE STYLE MODIFICATION : Discontinue NSAID Smoking cessation Alcohol cessation Reduce stress

17. Drugs used in PUD : P roton 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

18. MoA of anti- ulcerant Drugs

19. 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

20. 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 ).

21. THERAPY OF NSAID-RELATED GASTRIC OR DUODENAL INJURY

22. 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.

23. 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.

24. Surgical treatment Indications: Failure of medical treatment. Development of complications High level of gastric secretion and combined duodenal and gastric ulcer.

25. Types of Surgical Procedures Gastroenterostomy Vagotomy Gastrectomy - Billroth -1, Billroth-2

26. Post-op Complications : Dumping syndrome Bile reflux gastropathy Diarrhe o a and Malabsorption Weight loss Anemia Osteoporosis and osteomalacia G a stric cancer

27. 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

28. 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/

29. 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 ).

30. 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. • Harrison principle of medicine 21 st edition • Kumar and clark internal medicine 10 th edition •Davidson medicine and principle of practice 24th edition and treatment. Postgrad Med 2005;117(6): 17-22, 46

31. Thank you