Peptic Ulcer Disease (4.4) Flashcards
What is peptic ulcer disease (PUD)?
PUD is a term used to describe a group of ulcerative disorders that occur in areas exposed to acid-pepsin secretions
>gastric ulcer
>duodenal ulcer
>gastric erosions
>duodenal erosions
What are some signs and symptoms of PUD
- Pain described as burning or gnawing and constant
- Stomach ulcer: pain worsen after eating; duodenal ulcer: pain relieved by food
- Waking up at night with pain
- Non specific Sx: bloating, belching, heartburn,nausea
What are some complications of PUD
GI bleeding
- Insidious (+ve faecal occult blood test)
- Sudden, severe and without warning (haematemesis, melaena, weakness, syncope, increased Urea)
Penetration into an adjacent organ
- intense and persistent pain, radiating to other sites
Gastric outlet obstruction (2%)
- bloating, fullness, large volume vomiting
What are some alarm symptoms of PUD?
- Unintentional weight loss
- Haematemesis (vomiting blood or coffee-grounds like material)
- Melaena (black, tarry faeces)
- Iron deficiency anaemia
- Dysphagia & odynophagia
- Persistent vomiting, large volume vomiting
- On NSAIDs or warfarin
- >55 years if Sx persist in spite of initial management
For PUD;
A) Who is the patient
B) What are the symptoms?
C) How frequent are the symptoms
D) Action taken?
E) Medications?
F) Allergies?
A)
Caution in patient >55 yo due to increased risk of pathological condition
B)
- Location of pain
>Localised epigastric pain
>Pain relieved by food? (duodenal ulcer)
- Nature of pain
>Pain that wakes patient up at night
- Any alarm symptoms?
C)
Pain with remission and relapses
D)
- Has patient taken any PPI?
- Any relieve from PPI?
E)
- Are they on any medication that could potentially cause or increase risk of PUD
F)
- Any previous allergic reaction to medication?
Patient presenting with symptoms of PUD need to be referred for accurate diagnosis
What are some causes of PUD?
Helicobacter pylori infection
- 95% of DU and 85% of GU are associated with H.pylori
- No symptoms in most infected patient
Non-steroidal anti-inflammatory drugs (NSAIDS) (including low-dose aspirin)
- 15% of GU and 5% of DU among chronic NSAID users
Zollinge-Ellison Snydrome (rare)
- Malignant tumour on the pancreas or duodenum; overproduction of gastric and acid
When is H pylori screening indicated in individuals?
- Past or present history of PUD
- Uncomplicated non-ulcer dyspepsia
- Users of NSAIDs (inc low dose aspirin)
- Personal hx of gastric cancer
- Close relatives with gastric cancer
How does diagnosis of H pylori infection occur?
Serology
- Presence of H. pylori specific IgG antibodies
- Inexpensive and widely available
- Not suitable for monitoring post-eradication
Urea breath test
- Uses principle of urea metabolism by H. pylori
- Suitable for post-eradication test
- Urease is not present in human cells, its detection means that a urease producing organism (H pylori) is present
- Patient swallows a 13C-urea capsule
- Capsule comes in contact with gastric mucosa
- If urease is present, it splits the urea into CO2 and NH3. C02 is absorbed into the stomach lining & exhaled in the breath as labelled 14CO2
- Breath samples are collected at a timed sequence of 6,12, 20 mins after ingestion of capsule
- The breath samples are then analysed with a liquid scintillation counter for the level of radioactivity
Stool antigen test
- Presence of H. pylori antigen in the stool
Stop PPIs at least 2 weeks before the test and antibacterial 4 weeks before the test for an accurate result
What is the aim of H pylori eradication? Provide the regimen used for eradication and why resistance might fail
Aim: speeds up ulcer healing and reduces the chance of recurrent ulcer
If penicillin allergy: use metronidazole 400mg bd instead of amoxicillin 1000mg bd
- Not curative in all patients > confirm eradication four weeks after completing regimen
- True re-infection in Australia is uncommon after successful eradication
Reasons why first-line eradication might fail:
- Incomplete adherence: side effects, tablet burden, duration
- Resistance: clarithromycin 6-8%, metronidazole 50%, Amoxycillin still low
- Other issues: clarithromycin drug interaction
What is a alternative H pylori eradication regime
How do NSAIDs cause gastric mucosal damage?
- Direct irritation of the gastric mucosa
- Systemic inhibition of the protective mucosal prostaglandin synthesis
Endoscopically confirmed gastric and duodenal ulcers occur in 15-30% of chronic NSAIDs users
- Risk is increased with presence of other risk factors
- More common in those recently started on NSAIDs; greatest risk in first month
- Peptic ulcers induced by NSAIDs are gastric, often silent, presenting with acute complications
What are some other medications that increase the risk of NSAID-induced ulcers?
- Clopidrogel
- Sertraline, citalopram, escitalopram, fluxoetine, fluvoxamine
- Prednisolone
How to prevent NSAID induced PUD?
Minimize NSAID use
> Simple analgesics & non-pharmacological tx
If NSAID required
> Least toxic, lowest possible dose, shortest acting, use for as short a time as possible
For patients with a past history of ulcer disease: test and treat for H.pylori before starting NSAID use
>Helicobacter pylori infection + NSAID –> increases the risk of ulcer disease 60-fold and bleeding amount of 6-fold
Prophylaxis in patients with one or more risk factors
- Standard dose PPI
- Double dose H2 antagonists
- Misoprostol (poorly tolerated)
Do Cox-2 selective NSAIDs reduce risk of PUD?
Celecoxib, etoricoxib, meloxicam, parecoxib
- Selective Cox-2 inhibitors reduce BUT do not eliminate risk of PU
- Cox-2 inhibitors + low dose aspirin = no risk reduction for an ulcer
- Increased risk of cardiovascular events
How to manage NSAID induced ulcer?
Stop the NSAID (exclude low dose aspirin) to allow ulcer to heal
>Simple analgesic if analgesic required
- Heat ulcer with a standard dose PPI for 8-12 weeks
- Test and treat for H pylori after ulcer has healed
- AVOID NSAIDs in the future if possible
