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PEPTIC ULCER

Fauzi YusufGastroenterohepatologi Division

Internal Medicine DepartmentSyiah Kuala University/Zainoel Abidin Hospital

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PEPTIC ULCER

Incidens in Western Contries:Female 4 15 % & Male 10 15 %Patient Problem:Suffer recurrency / relaps, loss in theworks, cost of medication expensiveUpper GI endoscopy in Cipto Mangunkusumo

Hospital:The incidene of Peptic Ulcer: 6,93 7,10%;Duodenal Ulcer: Gastric Ulcer = 2:1

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Common Causes of Death in U.S.

0

1

2

3

4

5

6

7

8

9

Leukemia AIDS NSAID-GI

disease

Melanoma Asthma Cervical

cancer

D e a

t h p e r 1

0 0

, 0 0 0

Wolfe et al. NEJM 1999

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Type of Prevalence of upper gastrointestinal disease (UGI) indyspepsia cases, Internal Medicine Dept. Faculty of Medicine /Cipto Mangunkusumo Hospital and Zainoel Abidin Hospital Banda

AcehType of Disease RSCM

(1994)RSUZA

(2001/2002)

Normal

Gastritis/erosive GastritisDuodenitisEsophagitisBile Reflux Gastritis

Duodenal UlcerGastric UlcerPortal Hypertensive gastropathyGastric Tumor

Others

28

44,677,675,834,5

3,52,21,21

3,16

17,5

40,57,05

10,701,05

2,0371,053,050,95

0,024

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DEFINITION

Peptic Ulcer: Damage of mucosallayer/muscularis mucosa or deeper untilsubmucosa of the stomach/duodenum, ulceredge surounded by acute and chronicinflamatory cells; the diameter 5 mm Erosion: damage < 5 mm and the depth not

over than muscularis mucosa

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Differences between NSAID and H.pyloriinduced ulcers

NSAIDs induced H.pylori

Patients demographics Elderly more than youngWomen more oftenthan men

Young more often thanelderlyMen more often thanwoman

Site of damage Gastric more thanduodenal

Duodenal more thangastric

Symptoms More often

asymptomatic

Usually pain and or

dyspepsiaHistology Surrounding mucosa

normal(foveolar hyperplasia)

Surrounding mucosainflammed(active chronicgastritis)

Scarpignato,1997

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Risk Factors for NSAIDs InducedGastroduodenal Ulceration

Established Possible

Advanced age Concomitant infection withHistory of ulcer H. pyloriConcomitant use of glucocorticoids Cigarette smokingHigh-dose NSAIDs Alcohol consumptionMultiple NSAIDsConcomitant use of anticoagulantsSerious or multisystem disease

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Bicarbonate

PROTECTIVEFACTORS

Prostaglandins

Mucosal bloodsupply

Surfaceepithelial

cells

Mucus layer

AGGRESSIVE FACTORS

Acid + pepsin H. pylor i

Seager & Hawkey, BMJ 2001; 323 : 1236 9.

Pathogenesis of NSAID-induced ulcers

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Peptic Ulcer Clinical Manifestation

1. History of illnessNoneDyspeptic Symptom:

Epigastric Pain, Nausea, Vomiting,anorexia,epigastric discomfort, etcEpigastric PainEpisodic, Nocturnal, Pain -Food- Relief pattern

can be pointed atLoss of body weightHematemesis and Melena

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Peptic Ulcer Clinical Manifestation (Cont)

2. Physical Examination: Epigastric Pain,bloating, succusion splash (obstruction),anemia (bleeding), Perforation symptom

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Diagnosis ofHelicobacter Pylori Infection

NON-INVASIVEUrea Breath TestSerum serology for Hpantibody testWhole blood serology forHp antibody testSaliva Assay for Hpantibody test

Helicobacter Pylori stoolantigent (HpSA) test

INVASIVE(biopsy & endoscopy)

Culture test

Histopatology testUrease testPCR

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MANAGEMENT

General/supportifStop/Inhibit aggressive factorIncrease the defensive factorOther treatmentThreat the complication

Avoid ulcer relaps/recurrence

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Indication of Upper Gastrointestinal/Esophago-gastro-duodenoscopy

Age over 45 years old Alarm signsTherapy failureHistory of Peptic ulcer + ComplicationPatient enqueryThe use of aspirin or NSAID

Abnormality in Upper GI X-Ray (OMD)

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H Pylori Eradication (KSHPI)

Tripple therapy (1 or 2 weeks):PPI + Amoxicillin + ClarithromycinPPI + Metronidazole + ClarithromycinPPI + Metronidazole + Tetracyclin (Alergy to clarithromycin)

Quadrupple therapy ( 1 or 2 weeks):If fail to therapy combination 3 drugs:

Bismuth + PPI + Amoxicillin + ClarithromycinBismuth + PPI + Metroniudazole + Clarithromycin

High resistency area :PPI + Bismuth + Tetracyclin + Metronidazole

PPI 2 x/d: Omeprazole/Esomeprazole 20 mg, Lansoprazole 30mg, Pantoprazole 40 mg, Rabeprazole 10 mg Amoxicillin 2 x 1000 mg/d, Clarithromycin 2 x 500 mg/d,metronidazole 3 x 500 mg/d, tetracyclin 4 x 250 mg/d, Bismuth 4x 120 mg/d

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CONCLUSIONS

The three aims of ulcer treatment are :Symptom relief, Healing of the ulcer,prevention of recurrence.

For H Pylori Positive, Eradication therapyshould be given to prevent ulcer recurrenceFor optimal ulcer healing, NSAIDS should be

stop is possible.

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