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Barium StudiesStill commonly used as a first test for
documenting an ulcer80% sensitivity : single contrast barium study90% sensitivity: double contrast barium studySensitivity is low for small ulcers (<0.5 cm)Duodenal ulcers appear as a well demarcated
crater most often seen at the bulbGastric ulcers may either be benign or
malignant
Barium StudiesBenign gastric ulcer appears as a discrete
crater with radiating mucosal folds originating from the mucosal margin
Ulcers >3 cm are more often malignant
Radiographic studies that show a gastric ulcer must be followed by endoscopy and biopsy.
Fauci, et. al. Harrison’s Principles of Internal Medicine, 17 th ed.
EndoscopyMost sensitive and specific Direct visualization of the mucosaPhotographic documentation of the defectTissue biopsy to rule out malignancy or H.
pylori.Helpful in identifying lesions too small to
detect by radiographic examination, evaluation of atypical radiographic abnormalities, or to determine if an ulcer is a source of blood loss
Fauci, et. al. Harrison’s Principles of Internal Medicine, 17 th ed.
Detection of H. pyloriNON-INVASIVE
Serology Detection of antibodies in the serum
Urea Breath Test Simple, rapid, early follow up
Stool antigen Sensitive, specific, and inexpensive
Fauci, et. al. Harrison’s Principles of Internal Medicine, 17 th ed.
Detection of H. pyloriINVASIVE (Endoscopy/Biopsy required)
Rapid urease Simple, false negative with recent use of PPIs,
antibiotics, or bismuth compounds
Histology Provides histologic information
Culture Time-consuming, expensive
Fauci, et. al. Harrison’s Principles of Internal Medicine, 17 th ed.
ObjectivesPain reliefHealingPrevention of complicationsPrevention of recurrences
AntacidsRarely used as a primary therapeutic agents
but are instead used for symptomatic reliefMixture of aluminum hydroxide and
magnesium hydroxideEg. Maalox, Mylanta
Fauci, et. al. Harrison’s Principles of Internal Medicine, 17 th ed.
H2 Receptor AntagonistsInhibit basal and stimulated acid secretionOften used for treatment of active ulcers (4-6
weeks) in combination with an antibiotic directed at eradicating H. pylori.
Eg. Cimetidine, Ranitidine, Famotidine, Nizatidine
Fauci, et. al. Harrison’s Principles of Internal Medicine, 17 th ed.
Proton Pump InhibitorsSubstituted benzimidazole derivatives that
covalently bind and irreversibly inhibit H+K+-ATPase
Eg. Omeprazole, Esomeprazole, Lansoprazole, Rabeprazole, Pantoprazole
Fauci, et. al. Harrison’s Principles of Internal Medicine, 17 th ed.
Cytoprotective AgentsSucralfate
Insoluble in waterViscous paste within the stomach and duodenum,
binding primarily to sites of active ulceration
Bismuth-containing compoundsUlcer coating; prevention of further pepsin/HCl-
induced damage; binding of pepsin; and stimulation of PGs, bicarbonate, and mucous secretion
Prostaglandin AnaloguesEnhancement of mucosal defense and repairEg. Misoprostol
Fauci, et. al. Harrison’s Principles of Internal Medicine, 17 th ed.
THERAPY FOR H. pyloriEradication of H. pylori is the primary goal
DRUG DOSE
TRIPLE THERAPY
1. Bismuth subsalicylate plus Metronidazole plus
Tetracycline
2. Ranitidine bismuth citrate plus Tetracycline plus
Clarithromycin or Metronidazole
3. Omeprazole (lansoprazole) plus Clarithromycin plus
Metronidazole or Amoxicillin
2 tabs qid250 mg qid500 mg qid
400 mg bid500 mg bid500 mg bid
20 mg bid (30 mg bid)250 or 500 mg bid500 mg bid1 g bid
DRUG DOSE
QUADRUPLE THERAPY
OmeprazoleBismuth subsalicylateMetronidazoleTetracycline
20 mg (30 mg) daily2 tablets qid250 mg qid500 mg qid
Fauci, et. al. Harrison’s Principles of Internal Medicine, 17 th ed.