Peptic ulcer

Chen Jie

Department of gastroenterology, The first affiliated hospital of Sun Yat-sen university

Ulcer

Erosion

Definition

Chronic ulcer occur in stomach and duodenum(Pathologically, ulcer is a lesion extending deeper into submucosa)

•Epidemiology A common disease in digestive system

No data are available about the exact incidence of peptic ulcer

worldwide

CO2 +H2O HCO3 HCO3

HCO3 HCO3

pH 2pH 3pH 4pH 5pH 6pH 7

H+ H+ H+ H+

Mucus

Bicarbonate

Epithelial cell

Bllod flow

Capillary

Artery of submucosa

Gastral cavity

Ideograph of gastric mucosa barrier

PGE (prostaglandin e)

EGF(epidermal growth factor)

Gastric acid and pepsin

Pathogenesis

Pathogenesis

Helicobacter pylori, Hp(transmission electron microscope )

Hp is an important etiological factor of peptic ulcer

Evidences

Detection rate of Hp in PU patients1

Recurence rate of PU after successful eradication of Hp

2

Cyclo-oxygenase (COX)(rate-limiting enzyme in PG synthesis)

Arachidonic acid

COX-1Tissue type

COX-2Induced type

NSAIDsProstaglandin

NSAIDs(non-steroidal anti-inflammatory drugs) is another important etiological factor of PU

(-)

(-)

Prostaglandin

Gastrointestinal tract

Physiological function

Inflammation

Inflammatory reaction

“No acid, no ulcer” --- Key role of gastric acid in the formation of peptic ulcer

Because the activation of pepsin is pH-dependent (pH<4)

Gastric acid and pepsin

Diagnosis and differential diagnosis

Symptom is the most important clue for clinical diagnosis

Typical upper abdominal pain: Chronic, periodic and rhythmical pain

Relieve after food eating or antacid using

(Attention: Symptomless or un-typical ulcer)

Complex ulcer: --ulcers occur in both gastric and duodenal mucosa Ulcer of pyloric canal: --usually cause pyloric obstruction

Postbulbar ulcer Macrosis ulcer: --size>2cm

Peptic ulcer in elderly people Symptomless ulcer --half of the NSAIDS-related ulcers are symptomless

Special type of peptic ulcer

Definite diagnosis of peptic ulcer depends on endoscopy examination:

--- may observe ulcer, take biopsy and

detect HP infection

Niche sign observed by X-ray barium meal examination may also provide evidence for definite diagnosis of peptic ulcer

---not as accurate as endoscopy detection

Pictures of PU under endoscopy

DU GU

X-ray barium meal examination --- Niche sign (direct sign of ulcer)

Virulence (biopsy specimen of gastric mucosa)

Histological examination Hp culture Rapid urease test

Non-virulence 13C or 14C urea breath test Hp antigen detection in stool Serologic examination of Hp antibody

Hp detection (routine)

Steiner silver stain of gastric mucosa, showing abundantly microorganisms scattered within mucus (dark arrow indicated)

Culture

Very small and translucent colony on the plate

Rapid Urease Test: urea in the reagent was broken down by Hp urease, then the PH value of the reagent changed, finally the yellow color of the reagent changed to read color

13C Urea Breath Test

(UBT)

Differential diagnosis Peptic ulcer need to be differentiated from

diseases with chronic upper abdominal pain Diseases of liver, gallbladder and pancreas, functional

dyspepsia

After the ulcer has been detected by endoscopy examination

The differential diagnosis of benign and malignant gastric ulcer is very important

---larger size, dirty moss, swollen and stiff surrounding mucosa---cancer--- Definite diagnosis must depend on biopsy and pathohistological examination!!

Gatric ulcer Gatric cancer

Benign and malignant gastric ulcer

Complications

Bleeding The most common complication The most common cause of massive hemorrhage o

f gastrointestinal tract Perforation Pyloric obstruction Canceration (GU, 1%)

Pyloric obstruction (DU 、 pyloric canal ulcer)

Temporary obstruction (caused by pyloric dropsy or pylorospasm during the active stage of ulcer)

Chronic obstruction (cicatricial pyloric obstruction) (caused by shrink of scar during the healing stage of ulcer)

Symptoms (abdominal pain, nausea, vomit, et al)

Confirmed by gastroscope or X-ray barium meal examination

TreatmentPrinciples

Eliminate etiological factors (Hp eradication, stop using NSAIDs)

Relieve symptoms, facilitate ulcer healing (antiulcer drugs)

Prevent ulcer recurrence, and prevent or treat complications

1. General treatment

---Stop smoking, stop drinking ,regular food-intake, et al

2. Anti-ulcer treatment

Types Commonly used drugs Recommend dosage

Acid inhibition drugs

Antacid Algeldrate, hydrotalcite et al

H2RA Cimetidine 800mg qN or 400mg bid

Ranitidine 300mg qN or 150mg bid

Famotidine 40mg qN or 20mg bid

PPI Omeprazole 20mg qd

Lansoprazole 30mg qd

Rabeprazole 10mg qd

Gastric mucosa protection drugs

Sucralfate Sucralfate 1g qid

Prostaglandins Misoprostol 200g qid

Bismuth compound Colloidal bismuth subcitrate 120mg qid

Anti-ulcer drugs

H2RA :Histamine H2 receptor antagonist; PPI :proton pump inhibitor

3. Hp eradication treatment

Hp must be eradicated in all

Hp-positive peptic ulcer!!

Proton pump inhibitor (PPI)

Two antibiotics

Colloidal Bismuth Subcitrate

Amoxicillin, Clarithromycin, Tetracycline, Metronidazole, Furaltadone…

+

(1) Hp eradication regimen

Or

A trigeminy regimen of Hp eradication

Omeprazole 20mg b.i.d

+ Clarithromycin 500mg b.i.d

+ Amoxicillin 1000mg b.i.d

×

7days

This is a widely used first-line Hp eradication regimem.

Ulcer patient with complications

Patient with large ulcer or recurrent ulcer

Symptom cannot be relieved after Hp

eradication

Above patients need to use PPI or H2RA for 2-

8weeks

(2)Anti-ulcer treatment after Hp eradication

(3) Detect Hp after eradication treatment

4 weeks after eradication treatment

---- to avoid false negative result

13C or 14C-UBT is the first choice

Detect Hp infection by gastroscope is necessary in

DU patients with complications, or in GU patients

with or without complications

4. Treatment and Prevention of NSAID-related ulcer

Treatment Stop using NSAIDs ， routinely give H2RA or PPI for tre

atment

For patients who can not stop using NSAIDs, give PPI, an

d maintain long term anti-ulcer treatment after ulcer heal

ing

For patients with Hp infection ， Hp eradication is also n

eeded

(NSAID and Hp are two independent ulcerogenic factors )

Prevention

Following patients need routine prevention treatment:

Patients with a history of peptic ulcer Elderly patients Patients using glucocorticosteroid or decoagulant (inclu

ding low-dosage asprin) together with NSAIDs

Prevention method:PPI, routine dosage

5. Prevention of peptic ulcer recurrence

2.Following patients need to maintain long term anti-ulcer treatment to prevent ulcer recurrence:

Patient who can not stop using NSAIDs

Hp can not be eradicated

Ulcer recurrence after Hp eradication

Non-Hp and non-NSAIDs ulcer Elderly patients Patients with serious concomitant disease

3. Prevention method: PPI or H2RA, routine dosage

1.Hp eradication and stop using NSAID may prevent peptic ulcer recurrence

6. Indication for surgery

Hemorrhea, medical treatment is

ineffective

Acute perforation

Cicatricial pyloric obstruction Gastric ulcer with canceration

Telephium, medical treatment is

ineffective

What is the etiopathogenisis of PU?

How to diagnose PU?

Chronic, periodic and rhythmical upper abdominal pain

Endoscopy (or X-ray barium meal ) examination for definite diagnosis

Routinely detect Hp

Common complications of PU?

• Bleeding

• Perforation

• Pyloric obstruction

• Canceration (GU, 1%)

Case one: How to treat a young patient with DU, upper gastrointestinal bleeding and Hp infection?

Hp eradication (for example, PPI+Amo+Cla, 1w)

Continue to treat with anti-ulcer drug (for example, omep

razole 20mg qd, 2w)

Take endoscopy examination

4w after eradication, take 13C or 14C urea breath test

Case two: How to treat a patient with gastric ulcer and Hp infection who needs to use NSAID for a long term?

Hp eradication (for example, PPI+Amo+Cla, 1w)

Continue to treat with PPI (for example, omeprazole 20mg

qd, 4w)

Take endoscopy examination

Continue long term maintenance treatment with PPI to pr

event recurrence (for example, omeprazole 20mg qd)

Thank you!