30. Treatment of gastric and duodenal ulcers

Question 1

what can gastric and duodenal ulcers be grouped into and why?

Answer 1

peptic ulcers

though they differ in terms of presentation and epidemiology, their treatment is the same

Question 2

what does the carbon-urea breath test do and how does it work?

Answer 2

detects the presence of H. pylori

the patient is given a lot of urea because H. pylori metabolises urea to nitrogen. if there are increased levels of nitrogen, H. pylori infection is present

Question 3

what does the stool antigen test do?

Answer 3

tests for H. pylori antigens in the stool of the patient

Question 4

what % of duodenal and gastric ulcers are due to H. pylori?

Answer 4

duodenal - 98-100%

gastric - 70-80%

Question 5

what is H. pylori?

Answer 5

a motile spirochete that is able to move around (due to its flagella)

it is a commensal bacteria that is present in the stomach

Question 6

how does H. pylori cause ulceration?

Answer 6

• a mucus layer protects the stomach epithelium from the acidic environment
• H. pylori can dissolve our mucus layer using urease enzyme allowing H. pylori to access epithelia –> epithelial cell death (exotoxins are released –> increased inflammation)
• eventually there is damage to the mucus layer, epithelial layer and interstitial layer –> ulceration

Question 7

what is the link between acidity and ulceration?

Answer 7

increased acidity –> peptic ulcer

increased acidity also –> increased cell production of protons –> even greater acidity –> further ulceration

Question 8

how are H. pylori infections treated?

Answer 8

amoxicillin and clarithromycin antibiotics

Question 9

what is used to reduce acid production?

Answer 9

proton pump inhibitor for 7 days

Question 10

what might you give alongside amoxicillin and clarithromycin?

Answer 10

quinolone or tetracycline if the H. pylori infection doesn’t go away

Question 11

give an example of a proton pump inhibitor and outline why they are necessary

Answer 11

omeprazole

• parietal cells produce H+ via proton pumps
• the main regulators of this are the cholinergic system and the histaminergic system
• parietal cells are also influenced by other cells in the stomach: cells in the fundus release somatostatin (reduce parietal cell activity) and gastrin (increase parietal cell activity)
• proton pump inhibitors are necessary for reducing the activity of proton pumps and reducing stomach acidity

Question 12

what is the second most common cause of peptic ulcers?

Answer 12

prolonged NSAID usage

Question 13

in what ways are NSAIDs and H. pylori similar?

Answer 13

• NSAIDs can be directly cytotoxic
• they reduce mucus production
• this leads to a breakdown of the mucus barrier –> epithelia exposure –> ulceration

Question 14

in what ways are NSAIDs different to how H. pylori causes ulceration?

Answer 14

• NSAIDs may increase the likelihood of bleeding (acts as an anti-platelet agent)
• this can worsen the symptoms

Question 15

give an example of a histamine H2 receptor antagonist and outline what they do

Answer 15

ranitidine

• H2 receptor stimulation on parietal cells increases acid secretion due to increased activity of the proton pump
• an antagonist can be used to treat NSAID-induced peptic ulcers
• H2 receptor antagonists work together with proton pump inhibitors to reduce proton pump activity