Peptic Ulcer Disease

What is H. Pylori

Chronic disorders with ulceration in upper GI tract that occur when normal mucosal defense and healing is disrupted

Causes

H.Pylori

NSAID

Stress

Risk factors for NSAID induced Ulcers

Age >65

antiplatelet or coagulant use

SSRIs

Previous PUD or complication

Multiple NSAID therapy

Alcohol or smoking use

When to test for H.Pylori

Active PUD

Long term NSAID therapy

Hx of gastric cancer

Anyone with H. Pylori in the house

Invasive diagnostic method

Endoscopy

When is an endoscopy indicated

In alarm featurs

• GI bleeding

• Weight loss >10%

• Dysphagia

• Anorexia

  • PUD Hx

Gold standard of endoscopy

Biopsy

Biopsy results can be affects by

PPI

H2RA

Bismuth

Antibiotics

Non-invasive Diagnostic methods

Urea breath test

Stool antigen test

Serology Blood draw

Urea Breath test

Can test for cure

False negatives with

PPI

H2RA

Bismuth

Antibiotics

Stool antigen test

Can test for cure

False negatives with

PPI

H2RA

Bismuth

Antibiotics

Serology blood draw

only indicated the presence of antibodies

DOESNT TEST FOR CURE
NOT AFFECTED BY MEDS

Will Ulcers recur is cause is not eliminated

YES

Only patients with H. pylori infection AND symptoms should be trated

NO , even if no sx, H, pylori → tx

Can regimens be subsituted or shortened

NO

After 4 weeks of therpay eradication (or cure) must be confirmed what tests can be used

Breath test

Stool antigen

biopsy

FIRST LINE REGIMEN

Optimized Bismuth Quadruple Therapy (OBQT)

OBQT Duration

14 days

OBQT Dosing

1. Bismuth subsalicylate 300 mg QID

2. Metronidazole 500 mg TID-QID

3. Tetracycline 500 mg QID

   1. PPI standard BID dose

Rifabutin Triple Therapy (RTT) Duration

14 days

RTT dosing

1. Omeprazole 10 mg TID

2. Amoxicillin 250 mg TID

   1. Rifabutin 12.5 mg TID

Vonoprazan based (Potassium competitive acid blocker - PCAB)

DUAL

Duration - 14 days

Dosing

1. Vonoprazan 20 mg BID

2. Amoxicillin 1000 mg TID

Vonoprazan based

TRIPLE

Duration- 14 days

Dosing

1. Vonoprazan 20 mg BID

2. Amoxicillin 1000 mg BID

   1. Clarithromycin BID

Clarithromycin-based therapy

When to use

Bascially never unless

clarithromycin susceptibility

no prior macrolide exposure

no penicillin alergy

Therapy for pt with a PCN allergy 

OBQT

Best therapy for pt without a PCN allergy

OBQT

Additionaly therapy for pt without a PCN allergy

RRT

PCAB dual

PCAB triple

• DONT USE IF PREVIOUS EXPOSURE TO MACROLIDE

Metronidazole/TInidazole

No alcohol

Disulfram-like rxns

Effects tasteCl

Clarithromycin

when no susceptibility macrolides or dont know susceptiblity

effects taste

Tetracycline

Avoid in kids

Can discolor teeth

Photosensitivity

do NOT sub for doxy

Amoxicillin

Avoid in PCN allergy, can use metronidazole instead

PPI

take 30-60 min before meal

DO NOT sub for H2RA

Vonoprazan

can take with or without food

ADRs

• gastritis

• Abdominal pain