Dr Isbandiyah_Peptic Ulcer Disease

8/18/2019 Dr Isbandiyah_Peptic Ulcer Disease

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Peptic Ulcer Disease

Dr. Isbandiyah, SpPD



A peptic ulcer is a mucosalbreak, 3 mm or greater, thatcan involve the stomach or

duodenum

Definition



Peptic Ulcers:astric ! Dudodenal









"ucosa protective #actors



$tiology

• %he most important contributing #actors are H pylori, &SAIDs, acid, and pepsin.

• Additional aggressive #actors include smoking,ethanol, bile acids, aspirin, steroids, and stress.

• Important protective #actors are mucus,bicarbonate, mucosal blood 'o(,prostaglandins, hydrophobic layer, andepithelial rene(al.

– Increased risk (hen older than )* d+t decreaseprotection

• hen an imbalance occurs, PUD might develop.



Pathogenesis of Ulcers

Aggressive Factors Acid, pepsin Bile salts Drugs (NSAIDs) H. pylori

Defensive Factors Mucus, bicarbonate layer Blood flow, cell renewal Prostaglandins Phospholipid Free radical scavengers

Therapy is directed at enhancing host defense oreliminating aggressive factors; i.e., H. pylori.



Sub-ective Data

• Pain/gna(ing/, 0aching/, or 0burning/ – Duodenal ulcers: occurs 123 hours a#ter a meal and

may a(aken patient #rom sleep. Pain is relieved by#ood, antacids, or vomiting.

– astric ulcers: #ood may eacerbate the pain (hilevomiting relieves it.

• &ausea, vomiting, belching, dyspepsia,bloating, chest discom#ort, anoreia,

hematemesis, !+or melena may also occur. – nausea, vomiting, ! (eight loss more common (ith

astric ulcers



4b-ective Data

• $pigastric tenderness

• uaic2positive stool resulting #rom occult blood loss

• Succussion splash resulting #rom scaring or edemadue to partial or complete gastric outlet obstruction

– A succussion splash describes the sound obtained byshaking an individual (ho has #ree 'uid and air or gas in ahollo( organ or body cavity.

– Usually elicited to con5rm intestinal or pyloric obstruction.

– Done by gently shaking the abdomen by holding either

side o# the pelvis. A positive test occurs (hen a splashingnoise is heard, either (ith or (ithout a stethoscope. It isnot valid i# the pt has eaten or drunk 'uid (ithin the lastthree hours.



Diagnostic Plan

• Stool #or #ecal occult blood

• 6abs: 787 9+4 bleeding;, liver #unction test,amylase, and lipase.

• <. Pylori can be diagnosed by urea breath test,blood test, stool antigen assays, ! rapid ureasetest on a biopsy sample.

• Upper I $ndoscopy: Any pt =)* yo (ith ne(

onset o# symptoms or those (ith alarmmarkings including anemia, (eight loss, or Ibleeding.



%reatment Plan: <. Pylori

• "edications: %riple therapy #or 1> days is considered thetreatment o# choice. – Proton Pump Inhibitor ? clarithromycin and amoicillin

• 4mepra@ole 9Prilosec;: * mg P4 bid #or 1> d or6ansopra@ole 9Prevacid;: 3* mg P4 bid #or 1> d or

abepra@ole 9Aciphe;: * mg P4 bid #or 1> d or$somepra@ole 9&eium;: >* mg P4 Bd #or 1> d plus7larithromycin 98iain;: )** mg P4 bid #or 1> andAmoicillin 9Amoil;: 1 g P4 bid #or 1> d

• 7an substitute Clagyl )** mg P4 bid #or 1> d i# allergic

– In the setting o# an active ulcer, continue Bd protonpump inhibitor therapy #or additional (eeks.

• oal: complete elimination o# <. Pylori. 4nce achievedrein#ection rates are lo(. 7ompliance



%reatment Plan: &ot <.Pylori

• "edicationstreat (ith Proton PumpInhibitors or < receptor antagoniststo assist ulcer healing

– <: %agament, Pepcid, Aid, or Eantac#or up to F (eeks

– PPI: Prilosec, Prevacid, &eium, Protoni,

or Aciphe #or >2F (eeks.



6i#estyle 7hanges

• Discontinue &SAIDs and use Acetaminophen#or pain control i# possible.

• Acid suppression22Antacids

•Smoking cessation

• &o dietary restrictions unless certain #oodsare associated (ith problems.

• Alcohol in moderation –

"en under G): drinks+day – "en over G) and all (omen: 1 drink+day

• Stress reduction



7omplications

• Per#oration ! Penetrationintopancreas, liver and retroperitoneal space

• Peritonitis

• 8o(el obstruction, astric out'o(obstruction, ! Pyloric stenosis

• 8leeding22occurs in )H to 33H o# cases

and accounts #or )H o# ulcer deaths.• astric 7A



Surgery

• People (ho do not respond to medication, or(ho develop complications: – agotomy 2 cutting the vagus nerve to interrupt

messages sent #rom the brain to the stomach to

reducing acid secretion. – Antrectomy 2 remove the lo(er part o# the stomach

9antrum;, (hich produces a hormone that stimulatesthe stomach to secrete digestive -uices. A vagotomyis usually done in con-unction (ith an antrectomy.

– Pyloroplasty 2 the opening into the duodenum andsmall intestine 9pylorus; are enlarged, enablingcontents to pass more #reely #rom the stomach. "aybe per#ormed along (ith a vagotomy.



$valuation+Collo(2up+e#errals

• <. Pylori Positive: retesting #or t eJcacy• Urea breath testno sooner than > (eeks a#ter

therapy to avoid #alse negative results

• Stool antigen testan F (eek interval must be

allo(ed a#ter therapy.

• <. Pylori &egative: evaluate symptomsa#ter one month. Patients (ho arecontrolled should cont. 2> more (eeks.

• I# symptoms persist then re#er tospecialist #or additional diagnostictesting.

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Dr Isbandiyah_Peptic Ulcer Disease