peptic ulcer disease

peptic ulcer disease

• acid related damage to the muscularis mucosa

• most commonly caused by Helicobacter pylori infection, NSAIDs, and stress ulcers

clinical presentation of peptic ulcer disease

• mild epigastric pain

• nocturnal pain (0000-0300)

• heatburn

• belching

• nausea

• vomitinig

• anorexia

• low H/H

• blood in stool (positive hemoccult tests)

• bloating

• EGD

gastroesophageal reflux disease

• burning sensatin rising from stomach to chest

• exacerbated by some foods (alcohol, garlic, spicy foods)

peptic ulcer disease

• pain/discomfort in central abdomen

• relieved by eating and drinking

ulcer complications

• upper GI bleed

• GI perforation

• obstruction

causes of PUD

• H pylori

• NSAIDS

• stress induced

diagnosis of H pylori

• require endoscopy → rapid urease test (biopsy)

• no endoscopy→ urea breath test

2

• hold PPIs/H2RAs __ weeks before testing with rapid urease test

4

• hold bismuth/antibiotics__ weeks before testing with rapid urease test

1-2

• hold PPIs/H2RAs __ weeks before testing with urea breath test

4

• hold bismuth/antibitoics __ weeks before testing with urea breath test

urea breath test

• recommended test to confirm post treatment eradication

recommended regimens for PUD naive patients

• optimized bismuth quadruple (BQT) → first line

• Ribabutin triple (Talicia)

• PCAB Dual (Voquenza Dualpack)

• PCAB triple (Voquenza TriplePak)

optimized bismuth quadruple

• first line for PUD naive patient

• PPI

• bismuth subsalicylate

• tetracycline

• metronidazole

14 days

• duration of treatment for PUD naive patients

Talicia

• Rifavutin triple brand name

Rifabutin triple

• omeprazole

• amoxicillin

• rifabutin

Voquenza DualPak

• brand name for PCAB dual

PCAB Daul

• vonoprazan

• amoxicillin

Voquenza triplepak

• brand name for PCAB triple

PCAB triple

• vonoprazan

• clarithromycin

• amoxicillin

amoxicillin

• take with food

• may cause GI upset, diarrhea

rifabutin

• take with food

  • may discolor urine, serious skin rashes

clarithromycin

• take ER formulation with food

• QTc prolongatoin

tetracycline

• take without food, take with plenty of fluids

• avoid within 2 hours of antacids

• photosensitivity, teeth discoloration, and bone devleopment issues in children, binds to divalent/trivalent cations

metronidazole

• take with food

• avoid alcohol

• nausea metallic taste, long term neurotoxicity

levofloxacin

• avoid within 2 hours of antacids

• photosensitivity, tendinitis, neurotoxiicty, QTc prolongation, glucose dysregulation, hepatotoxicity

treatment experienced PUD

• optimized BQT if haven’t received yet

• if have received optimized BQT → rifabutin triple therapy

• if proven clarithromycin sensitive, can use PPI- or PCAB based clarithromycin triple therapy

• last line → levofloxacin triple therapy if proven levofloxacin sensitive

• high dose PPI/PCAB dual therapy with amoxicillin is not recommended

4 weeks

• all patients who are treated for H pylori infection should undergo a test of cure with an appropriately conducted urea breath test, fecal antigen test, or biopsy based test at at least ____ after completion of therapy

NSAIDs

• cause superficial mucosal damage that usually heals but can progress to erosions with continued use

• risk depends on dose, frequency, duration, and selectivity of NSAID

Cox 2 selective NSAIDS

• celecoxib

• diclofenac

• etodolac

• meloxicam

risk factors for NSAID induced PUD

• age > 65

• previous peptic ulcer

• previous ulcer related upper GI complication

• mutliple NSAID use

• NSAID-related dyspepsia

• chronic debilitating disorders

• H pylori infection

• alcohol/smoking

• concomitant use of NSAIDs plus: aspirin, oral bisphosphonates, steroids, anticoagulants, antiplatelets, SSRIs

treatment for NSAID induced PUD

• stop (or interrupt) NSAID

• administer H2RA, PPI, or sucralfate x 8 weeks

• if must give NSAID: administer PPI or misoprostol

• prefer COX2 selective

• if symptoms are unresolved after 8 weeks, test for H pylori

8 weeks

• treatment duration for NSAID induced PUD

misoprostol BBW

• pregnancy category X

naproxen + PPI/misoprostol

high CV risk NSAID induced PUD with moderate or low GI risk

COX 2 inhibitor + PPI/misoprostol

• if low CV risk but high GI risk

NSAID alone

• low CV risk and low GI risk

stress related uclers

• mucosal ischemia is caused by decreased blood flow between stomach to splanchnic region

• ischemia plus stress from critical illness causes lesions to form

• prophylaxis options = PPI or H2RA

duodenum

• stie of damage for H pylori induced ulcer

stomach

• site of damage for NSAID induced ulcer

superficial

• H pylori ulcer depth

deep

• NSAID induced ulcer depth