PUD
Management
*the aim of management are to:
1- relieve symptoms
2- induce healing
3- prevent recurrence
*the cornerstone of mx is H pylori eradication
H pylori eradication
*indications:
1- definite: PU, HP +ve dyspepsia, MALToma
2- not indicated: GERD, asymptomatic
3- uncertain: family hx of gastric cancer,Non-ulcer dyspepsia, long term NSAID users
*types of therapy :
1- primary: for all patients with proven acute or chronic DU & those with GU who are HP +ve should be offered as primary therapy.
2- second line therapy: should be offered to those who remain infected after initial therapy .
3- third line treatment: used for those who are still colonized after two treatments so either treated with quadruple therapy (bismuth, PPI, & 2 AB) ORLong term maintenance therapy with acid suppression
Treatment consist of:
Medical treatment:
() PPI with 2 AB (amoxicillin, clarithromycin & metronidazole )
() duration: 7 days
() success rate : 90 %
() side effects:
*diarrhea
*30-50% pseudo membrasnous colitis
*flushing & vomiting
*nausea
*abdominal cramp
*headache
*rash
@PPI: Directly inhibit acid secretion by the parietal cell.
@ Bismuth subcitrate:
Coats ulcer at low pH, thus promoting healing
Causes black tongue
Must be taken at least half an hour before meals
Assists H Pylori eradication
@sucrulfate
Forms a protective barrier at ulcer site
Few adverse effects: constipation, headache
Avoid in renal impairment
Taken 1 hr before meals, avoid with other drugs
Misoprostol
PGE analogue
Protects GI mucosa
Used for PUD and prophylaxis against NSAID induced ulcers
AVOID in PREGNANCY
Appears safe in lactation
() general measures: should avoid:Smoking, aspirin & NSAID, Alcohol in moderation is not harmful???, No special dietary advice is required ????????
() Patients who are taking (NSAIDs) may also be prescribed a prostaglandin analogue (Misoprostol) in order to help prevent peptic ulcers
() surgical treatment:
*elective surgery for PUD is rare.
*partial gastrectomy with Billroth I & II anastomosis or vagotomy
* indications:
()emergency: perforation ,hemorrhage
() elective: either complications(gastric outflow obstruction) or recurrent ulcer following gastric surgery.
*complications of gastric resection or vagotomy:
1- dumping: rapid gastric emptying leads to distension of the proximal small intestine as the hypertonic contents draw fluid into lumen , this will lead to abd discomfort & diarrhea after eating . So the patients should avoid large meals with high CHO
2- bile reflux gastritis: may lead to chronic gastritis , its usually asymptomatic.Symptomatic treatment with aluminium containing antacid or sucralfate. Afew pt may require revisional surgery.
3- diarrhea & maldigestion: usually develop 1-2 hr after eating.diarrhea often response to dietry advice to eat small, dry meals with reduced intake of refined CHO, antidiarrheal drugs may needed
4- wt loss: occur in most pt, because of small gastric remnant, diarrhea
5- anemia: IDA, folic acid & B12 deficiency
6- metabolic bone disease: both osteoprosis & osteomalacia can occur as a consequence of ca & vit D malabsorption.
7- gastric cancer
Complications of PUD
1- perforation:
()more common in duodenal ulcer
() mostly on the ant wall
()1/4 of perforation occur in acute ulcer or NSAID
() may be the 1st sign of ulcer, lead to peritonitis, absent bowel sounds.
()CXR : erect show free air under the diaphragm.
() MR 25%.
2- gastric outlet obstruction:
() pyloric stenosis from fibrotic stricture.
() odema from DU
()ca of antrum
()adult hypertrophic pyloric stenosis.
3- bleeding
Prevention
**Primary prevention of NSAID-induced ulcers includes the following:
1- Avoid unnecessary use of NSAIDs.
2- Use acetaminophen when possible.
3- Use the lowest effective dose of an NSAID and switch to less toxic NSAIDs, such as the newer NSAIDs or cyclooxygenase-2 (COX-2) inhibitors,Consider prophylactic or preventive therapy for the following patients:
1- Patients with NSAID-induced ulcers who require chronic, daily NSAID therapy
2- Patients older than 60 years
3- Patients with a history of PUD or a complication such as gastrointestinal bleeding
4- Patients taking concomitant steroids or anticoagulants or patients with significant co morbid medical illnesses
Zollinger-Ellison syndrome
() this is rare disorder characterised by the triad of:
*severe peptic ulceration
*gastric acid hypersecretion
*non-beta cell islet tumor of pancreas(gastrinoma)
()0.1% of DU mostly ( 30-50 years)
()presented with severe, multiple, unusual sites
()treated with large doses of PPI 60-80 mg dially & some times octreotide. a
Non-ulcer dyspepsia
() define as chronic dyspepsia in the absenceOf organic disease
()pt are usually young(<40 years), women are affected twice the men
()abdominal pain, nausea, bloating after meals, morning symptoms are characterestic
()endoscopy necessary in elderly to exclude malignancy.
() drug treatment is not especially successful
()antacids are sometimes helpful
() metoclopramide, or domperidone may be given before meal if nausea, vomiting is present
()H2receptors antagonist
()low dose of amitriptyline
() HP eradication remain controversial
gastroparesis
()defective gastric emptying without mechanical obstruction of the stomach or duodenum
()either primary due to inherited diseases or secondary due to diabetic neuropathy, systemic sclerosis, myotonic dystrophies , amyloidosis, drugs
()early satiety, recurrent vomiting, abd fullness & a succssion splash.
()Rx by small, frequent low fat meals, metocloprimide, surgical insertion of gastric pacing device .