PUD management

Gastric Ulcer (GU)

Pain is worse shortly after eating (food stimulates acid production, irritating the stomach lining). Patients often experience weight loss because they avoid eating.

Duodenal Ulcer (DU)

Pain occurs 2-3 hours after meals or wakes the patient up at night. Pain is often relieved by eating (food buffers the acid as it enters the duodenum). Associated with weight gain.

Alarm Symptoms (Red Flags)

Melena (black, tarry stools indicating upper GI bleed), hematemesis (vomiting blood or "coffee-ground" emesis), unexplained weight loss, and severe radiating abdominal pain (suggesting perforation). Presence of these requires immediate referral and often endoscopic evaluation.

H. pylori Eradication Regimens: First-Line: Triple Therapy (The Standard)

_{^{Used for 10-14 days. Remember the mnemonic PAC:}}

1. Proton Pump Inhibitor (PPI): e.g., Omeprazole 20mg BID or Pantoprazole 40mg BID.

2. Amoxicillin: 1g BID.

3. Clarithromycin: 500mg BID.

• _{^{If Penicillin Allergic: Swap Amoxicillin for Metronidazole 500mg BID (The PMC regimen).}}

H. pylori Eradication Regimens: First-Line Alternative: Bismuth Quadruple Therapy

_{^{Used for 10-14 days. Often used if the patient has previous macrolide exposure, if there is high local clarithromycin resistance, or as a second-line option if Triple Therapy fails. Remember the mnemonic PBTM:}}

• PPI: Standard dose BID.

• Bismuth Subsalicylate (or Subcitrate): 525mg QID (provides direct antibacterial action and mucosal protection).

• Tetracycline: 500mg QID.

• Metronidazole: 250-500mg QID.

Pharmacotherapy: Managing NSAID-Induced Ulcers

• First Step: Discontinue the NSAID if possible.

• Primary Treatment: Initiate a PPI (most effective for rapid healing) or an H2RA for 4-8 weeks.

• If NSAID must be continued (e.g., for severe rheumatoid arthritis)

If NSAID must be continued (e.g., for severe rheumatoid arthritis)

• Switch to a COX-2 selective inhibitor (like Celecoxib), which spares the GI protective COX-1 enzyme.

• Or continue the non-selective NSAID but add a daily PPI for prophylaxis.

• Or use Misoprostol (a synthetic PGE1 analog) for prophylaxis. (Note: Misoprostol is highly effective but poorly tolerated due to diarrhea and is contraindicated in pregnancy as it is an abortifacient).

Proton Pump Inhibitors (PPIs) (Omeprazole, Pantoprazole)

Mechanism of Action: Irreversibly bind to and inhibit the H^+ / K^+ ATPase pump on gastric parietal cells, shutting down final acid secretion.

Key Board Facts & Patient Counseling: Most potent acid suppressors. Must be taken 30-60 minutes before meals (require active acid secretion to be converted to active form). Long-term use risks: hypomagnesemia, B12 deficiency, increased fracture risk, and C. difficile infections.

H2 antagonists (Famotidine, Ranitidine, Cimetidine)

Mechanism of Action: Reversibly compete with histamine for H2 receptors on parietal cells, reducing basal and food-stimulated acid.

Key Board Facts & Patient Counseling: Effective, but less potent than PPIs. Often used for mild symptoms or nocturnal acid breakthrough. Cimetidine is a notorious CYP450 inhibitor (causes many drug interactions) and can cause gynecomastia (antiandrogenic effects).

Mucosal Protectants (Sucralfate)

_{^{Indicated for the management of duodenal ulcers, but it is also used in the treatment of gastric ulcers, GERD, and esophagitis.}}

Mechanism of Action: In acidic environments, forms a viscous, sticky polymer that binds to ulcer craters, creating a physical barrier against acid/pepsin.

Key Board Facts & Patient Counseling: Requires an acidic environment to work (do not take simultaneously with antacids or PPIs). Can bind to other drugs, reducing their absorption—separate by at least 2 hours. Causes constipation.

Prostaglandin Analogs (Misoprostol)

Mechanism of Action: Synthetic PGE1 analog. Replaces the protective prostaglandins inhibited by NSAIDs.

Key Board Facts & Patient Counseling: Primary use is preventing NSAID-induced ulcers. Major side effect is diarrhea. Black Box Warning: Abortifacient; absolutely contraindicated in pregnancy.

Antacids (Al/Mg Hydroxides, Ca Carbonate)

Mechanism of Action: Weak bases that chemically neutralize gastric acid in the stomach lumen.

Key Board Facts & Patient Counseling: For immediate symptomatic relief, not ulcer healing. Aluminum causes constipation; Magnesium causes diarrhea (often combined to balance bowel effects). Can chelate with antibiotics (fluoroquinolones, tetracyclines).