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Gastric and Duodenal Ulcer
What is a Peptic Ulcer?
• It is a hole that forms in the mucosal wall of the stomach, in
the pylorus (opening between stomach and duodenum), in the
duodenum (first part of small intestine), or in the esophagus.
• It is frequently referred to as a gastric, duodenal, or esophageal
ulcer, depending on its location, or as peptic ulcer disease.
• It is more likely to be in the duodenum than in the stomach.
• Chronic gastric ulcers tend to occur in the lesser curvature of
the stomach, near the pylorus.
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Risk Factors For Peptic Ulcers
• Infection with bacteria "Helicobacter pyloricus" (H. pylori).
• Gastritis, alcohol, smoking, use of NSAIDs, and stress.
• Familial tendency may be a significant predisposing factor.
People with blood type O are more susceptible to peptic ulcers
than are those with other types.
• Rarely, ulcers are caused by excessive amounts of the
hormone gastrin, produced by tumors. This Zollinger-Ellison
syndrome (ZES) consists of severe peptic ulcers, extreme
gastric hyperacidity, and gastrin-secreting benign or malignant
tumors of the pancreas.
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Clinical Manifestations
• Many people have symptomless ulcers, and in 20% to 30%
perforation or hemorrhage may occur without any preceding
manifestations.
• Dull, gnawing [persistent & troubling] pain or a burning
sensation in the midepigastrium. The pain may occur when the
increased acid content of the stomach and duodenum erodes
the lesion and stimulates the exposed nerve endings. Pain is
usually relieved by eating, or by taking alkali.
• Sharply localized tenderness can be elicited by applying gentle
pressure to the epigastrium at or slightly to the right of the
midline.
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• Pyrosis (heartburn), vomiting, and bleeding. Pyrosis is a
burning sensation in the esophagus and stomach that moves up
to the mouth.
• Heartburn is often accompanied by sour eructation, which is
common when the patient’s stomach is empty.
• Fifteen percent of patients with gastric ulcers experience
bleeding, as evidenced by the passage of tarry stools.
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Assessment and Diagnostic Findings
• A physical examination may reveal pain, epigastric tenderness,
or abdominal distention. Pain that is relieved by ingesting food
or antacids and absence of pain on arising are also highly
suggestive of an ulcer.
• Endoscopy is useful procedure because it allows direct
visualization of inflammatory changes, ulcers, and lesions. A
biopsy of the gastric mucosa and of any suspicious lesions can
be obtained. Biopsy and histology with culture can determine
H. Pylori.
• Stools may be tested for occult blood (OB).
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Medical Management
• The purpose of medical management of peptic ulcer is to
eradicate H. pylori and to manage gastric acidity. This is
achieved through pharmacologic therapy, lifestyle changes,
and surgical intervention. These are described next.
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Pharmacologic Therapy
• A combination of antibiotics (clarithromycin & amoxicillin),
proton pump inhibitors (omeprazole), and bismuth salts
(bismuth subsalicylate) that suppresses or eradicates H. pylori;
• Antibiotics assist in eradicating H. pylori bacteria.
• Histamine 2 (H2) receptor antagonists (Ranitidine) and proton
pump inhibitors are used to treat NSAID-induced and other
ulcers not associated with H. pylori ulcers.
• Bismuth salts suppress H. pylori bacteria in the gastric mucosa
and assists with healing of mucosal lesions.
• H2 receptor antagonists inhibit acid secretion by blocking the
action of the histamine on the histamine receptors in the
stomach.
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Life Style Changes
• Stress reduction and rest
– The patient may need avoid situations that are stressful or
exhausting. A rushed lifestyle and an irregular schedule may
aggravate symptoms and interfere with regular meals taken in
relaxed settings and with the regular administration of
medications.
– The patient may benefit from regular rest periods during the day,
at least during the acute phase of the disease.
• Smoking cessation
– Smoking decreases the secretion of bicarbonate from the
pancreas into the duodenum, resulting in increasing its acidity.
– Smoking may significantly inhibit ulcer repair. Therefore, the
patient is strongly encouraged to stop smoking.
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• Dietary modification
– Dietary modification is required to avoid oversecretion of acid
and hypermotility in the GI tract. Therefore, avoiding extremes
of temperature and overstimulation from consumption of meat
extracts, alcohol, coffee and other caffeinated beverages, and
diets rich in milk and cream.
– In addition, an effort is made to neutralize acid by eating three
regular meals a day.
• Surgery
– Surgery is usually recommended for patients with intractable
ulcers (those that fail to heal after 12 to 16 weeks of medical
treatment), life-threatening hemorrhage, perforation, or
obstruction.
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Standard doses of PPIs:
Esomeprazole 40 mg •
Pantoprazole 40mg •
Loseprazole 30mg •
Omeprazole 20mg •
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H. Pylori eradication
the first trial in Poland
10 – 14 days therapy: •
2 standard doses of PPI e.g. 2 x 40mg •
pantoprazole + 2 antibiotics from:
Amoxicilin 2 x 1000mg •
Metronidazole 2 x 500mg •
Clarithromycin 2 x 500mg •
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