Gastric and duodenal ulceration

Question 1

How can healing be promoted in those with peptic ulcers?

Answer 1

1) Smoking cessation
2) Taking antacids and by antisecretory drug treatment
↳ Relapse is common when treatment ceases

Question 2

Nearly all duodenal ulcers and most gastric ulcers are caused by what?

Answer 2

Helicobacter pylori (not usually associated with NSAIDs)

Question 3

what is the benefit of eradicating helicobacter pylori?

Answer 3

1) Reduces recurrence of gastric and duodenal ulcers
2) Reduces risk of rebleeding
3) Regression of (MALT) lymphomas

Question 4

Should H. pylori be confirmed before starting eradication treatment?

Answer 4

yes

Question 5

Outline the initial pharmacological treatment for H. pylori

Answer 5

A one-week triple-therapy regimen that comprises a:
1) Proton pump inhibitor
2) Clarithromycin
3) And either amoxicillin or metronidazole can be used
↳ BUT if a patient has been treated with metronidazole for other infections, amoxicillin would be used (PPI+clarith+amox) . Likewise, if a patient has been treated with a macrolide for other infections, a regimen using metronidazole is preferred (PPI+amox+metron)

Question 6

There is usually no need to continue antisecretory treatment following H. pylori eradication, except in which cases?

Answer 6

1) Ulcer is large
2) Complicated by haemorrhage or perforation
↳ In these cases antisecretory treatment is continued for a further 3 weeks.

Question 7

what are the main reasons for treatment failure in H pylori eradication?

Answer 7

1) Antibacterial resistance: Resistance to amoxicillin is rare. But, resistance to clarithromycin and metronidazole is common and can develop during treatment.
2) Poor compliance

Question 8

1) what benefit does two-week triple-therapy regimens offer and what are the draw backs?
2) why are two-week dual-therapy regimens not recommended?

Answer 8

1) Higher eradication rates compared to one-week regimens, but adverse effects are common and poor compliance is likely to offset any possible gain.
2) PPI and a single antibacterial are licensed, but produce low rates of eradication

Question 9

Tinidazole is also used occasionally for H. pylori eradication. what can this drug be used as an alternative to in the triple therapy regimen?

Answer 9

Metronidazole- Tinidazole should be combined with antisecretory drugs and other antibacterials.

Question 10

Routine retesting, to confirm eradication of H plyori is not required, unless the patient has which condition?

Answer 10

Gastric MALT lymphoma or complicated H. pylori associated peptic ulcer.

Question 11

what eradication regimen can be used in treatment failure?

Answer 11

1) A two-week regimen with PPI + tripotassium + tetracycline + metronidazole can be used for eradication failure.
2) Alternatively, can be referred for endoscopy and treatment based on the results of culture and sensitivity

Question 12

which test is used to diagnose H. pylori and which drugs should be avoided prior to testing? (2)

Answer 12

1) 13C-Urea breath test kit
2) The test involves collection of breath samples before and after ingestion of an oral solution of 13C-urea. The test should not be performed within 4 weeks of treatment with an antibacterial or within 2 weeks of treatment with an antisecretory drug.

Question 13

list the patients who are high risk of developing gastro-intestinal complications with a NSAID (4)

Answer 13

1) Over 65 years
2) History of peptic ulcer disease or serious GI complication
3) Taking other medicines that increase the risk of GI side-effects
4) Co-morbidity: CV, diabetes, renal or hepatic impairment

Question 14

in those at risk of ulceration what are the pharmacological options available for protection against gastric and duodenal ulcers associated with NSAIDS? (3)

Answer 14

1) PPI
2) H2-receptor antagonist e.g. Ranitidine given at twice the usual dose
3) Misoprostol

Question 15

which side effects might limit the dose of misoprostol prescribed and who is this drug usually reserved for?

Answer 15

1) Colic and diarrhoea may limit the dose

2) Most appropriate for the frail or very elderly from whom NSAIDs cannot be withdrawn

Question 16

when would a cyclo-oxygenase-2 selective inhibitor be considered in patients instead of an NSAID?

Answer 16

COX-2 with a PPI may be more appropriate for those with a history of upper GI bleeding or 3 or more risk factors for GI ulceration

Question 17

If treatment with a non-selective NSAID needs to continue in those who have developed an ulcer, what options can be considered?

Answer 17

1) Treat ulcer with a PPI and on healing continue the proton pump inhibitor
2) Treat ulcer with a PPI and on healing switch to misoprostol for maintenance therapy
3) Treat ulcer with PPI and switch non-selective NSAID to a COX-2 selective inhibitor; on healing, continue PPI in patients with a history of upper GI bleeding to provide further protection against recurrence.

Question 18

list 2 risk factors for GI bleeding and ulceration

Answer 18

NSAID use and H. pylori infection

Question 19

how should people who have developed an ulcer be managed?

Answer 19

1) Discontinue NSAID if possible. A PPI usually produces the most rapid healing.
2) Alternatively, the ulcer can be treated with a H2-antagonist or misoprostol. On healing, patients should be tested for H. pylori and given eradication therapy

Question 20

what precautions should be taken in women who are prescribed misoprostol?

Answer 20

1) Conception and contraception- do not use in women of childbearing age unless pregnancy has been excluded
2) In pregnancy it can induce uterine contractions and associated with defects. Teratogenic in first trimester