Peptic Ulcer Disease

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Slide 1:

Peptic Ulcer Disease Management: An Update Dr.ASM Rizwan

Bangladesh perspective:

In 1973 a rural hospital of 700 beds at Kumudini near Dhaka was having 70 positive barium meals a week and 30 operations a week for duodenal ulcer ! Tovey FI. Progress report peptic ulcer in India and Bangladesh . Gut. 1979; 20: 329-347. Bangladesh perspective

In the United states…:

4 million individuals (new cases and recurrences) affected per year Lifetime prevalence of PUD in the United States is ~12% in men and 10% in women. 15,000 deaths per year occur as a consequence of complicated PUD. Direct and indirect health care costs of ~$6 billion per year In the United states…

Causes:

Helicobacter pylori  infection NSAIDs Other medications like Steroids , bisphosphonates , potassium chloride , chemotherapeutic agents (e.g., intravenous fluorouracil) Causes

Less common Causes :

Acid- hypersecretory states (e.g., Zollinger - Ellison syndrome) Malignancy Stress After acute illness, multiorgan failure, ventilator support, extensive burns or head injury (Cushing's ulcer) Less common Causes

H.Pylori infection:

Common worldwide. Estimated prevalence is 70% in developing countries 30%–40% in the United States and other industrialized countries. H.Pylori infection

A bit of History:

H.Pylori was described over 100 years ago by Polish clinical researcher, Professor W. Jaworski Then in 1893 confirmed in animals by famous anatomist G. Bizzazero In late 1970s J.R. Warren, a pathologist in Perth, Australia, noted a spiral bacteria over inflammed stomach tissue. In 1982 Warren and B.J. Marshall cultured these organisms and fulfilled kochs postulate A bit of History

Slide 8:

Originally called Campylobacter pyloridis The name was changed to Campylobacter pylori Finally to Helicobacter pylori (H. pylori) 

2005 Nobel Laureate Marshall and Warren :

2005 Nobel Laureate Marshall and Warren

Acid-pepsin imbalance:

Acid-pepsin imbalance

Common sites:

Common sites

Slide 12:

Male:female = 2-5 :1(DU) & 2 : 1 (GU) Usually single DU: 50 % in 1 st part of duodenum and on anterior wall GU: 90 % on the lesser curve within the antrum or at body and antral junction Gu & DU coexist in 10% >1 ulcer found in 10–15% of patients.

Clinical presentation:

A bdominal pain which has three notable characteristics: Localisation to the epigastrium R elationship to food Episodic occurrence Clinical presentation

Less common presentation:

Unexplained anaemia Recurrent vomiting Early satiety Acute upper GI bleeding Recurrent acute bleeding Less common presentation

Investigations:

Investigations

Endoscopy:

Endoscopy

Managing PUD :

Aim of treatment: To relieve symptoms Induce healing Prevent recurrence Managing PUD

Non pharmacological…:

Cut off nicotin , Alcohol Discontinue inappropriate medication Maintain a healthy eating habit Non pharmacological…

Pharmacological …:

Two groups of drugs mainly Anti- ulcerant Anti-biotic Used in variable combination… Pharmacological …

Anti-ulcerants…:

Anti- ulcerants …

Surgical :

Partial gastrectomy with either— Billroath I reconstruction Billroath II reconstruction Surgical

Pharmacological treatment cont…:

Several treatment protocol exist.. Primary treatment is “Triple therapy” when idicated .. H.pylori proven Peptic ulcer Family history of gastric cancer Previous resection for gastric cancer H . pylori-positive dyspepsia Extranodal marginal-zone lymphomas of MALT type Pharmacological treatment cont…

Conventional Triple Therapy:

Omeprazole / Lansoprazole 20 / 30 mg BID 14 days Clarythromycine 500 mg BID Metronidazole / Amoxycilline 500 mg/ 1gm BID Conventional Triple Therapy

Checking treatment outcome..:

By --- Patient symptoms Endoscopy or non invesive tests… 1. UBT is the most reliable test to document eradication of H. pylori infection. 2. The monclonal fecal antigen test also establishes H . pylori cure after antibiotic treatment . Checking treatment outcome..

Slide 25:

Testing to prove H. pylori eradication appears to be most accurate if performed at least 4 weeks after the completion of antibiotic therapy.

TREATMENT FAILURE:

Non compliance Drug resistance Continued NSAID use Persistent stimulation eg : Gastrinoma TREATMENT FAILURE

NEXT STEP, if treatment fails:

Check drug compliance and local resistance pattern. Use salvage / 2 nd line therapy (Quadruple regimen). NEXT STEP, if treatment fails

Quadruple therapy:

Omeprazole / lansoprazole 20 / 30 mg Daily 10 -14 days Bismuth salicylate 2 tablets QID Metronidazole 250 mg QID Tetracycline 500 mg QID Quadruple therapy

Alternatively….:

Alternatively…. Rifabutin 150 mg Daily 12 days Pantoparzole 80 mg Amoxycilline 1 gm The overall eradication rate is 91%. Borody TJ, Pang G, Wettstein AR, et al. Efficacy and safety of rifabutin -containing ‘rescue-therapy’ for resistant Helicobacter pylori infection. Aliment Pharmacol Ther 2006;23:481–8 .

Re-Treatment failed?:

Re-Treatment failed?

Rescue therapy:

Levofloxacine 500 mg OD 10 days Esomeprazole 40 mg BID Clarythromycine 500 mg BID Rescue therapy It has > 90% success rate in eradicating H.pylori

Slide 32:

Several studies have reported eradication rates exceeding 84% with a “ novel sequential therapy ” consisting of A PPI and amoxicillin for 5 days Followed by … A PPI + Clarithromycin + Tinidazole for an additional 5 days

Eradication therapy complications:

Diarrhoea : 30–50% of patients; usually mild but Clostridium difficile -associated diarrhoea can occur Flushing and vomiting when taken with alcohol ( metronidazole ) Nausea , vomiting Abdominal cramps Headache Rash Eradication therapy complications

Slide 34:

Thank you

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