Peptic ulcer, assessment and management

Peptic ulcer are defined as circumscribed lesion in the mucosal membrane of the lower esophagus, stomach, duodenum, or jejunum....
Abdelwahab Ward, BS Pharm, PharmD

DESCRIPTION ã…¡ Peptic ulcer are defined as circumscribed lesion in the mucosal membrane of the lower esophagus, stomach, duodenum, or jejunum. Peptic ulcer occurs in TWO major forms: duodenal ulcer and gastric ulcer. Duodenal ulcer represents about 80% of peptic ulcers and affect the proximal part of the small intestine and follow a chronic course characterized by remissions and exacerbations.

          Pathophysiology. Helicobacter pylori releases a toxin that promotes mucosal inflammation and ulceration. In a peptic ulcer resulting from H. pylori, acid isn't the dominant cause of bacterial infection but contributes to the consequences. Ulceration stems from inhibition of prostaglandin synthesis, increased gastric acid and pepsin secretion, reduced gastric mucosal blood flow, or decreased cytoprotective mucus production.

Causes may be due to H. pylori infection (70%-90% duodenal ulcers). Use of nonsteroidal anti-inflammatory drugs (NSAIDs) or glucocorticoids may lead to 40%-50% gastric ulcers. Cigarette smoking, alcohol (ethanol) or pathologic hypersecretory states as Gastrinoma (Zollinger-Ellison syndrome). Risk factors include type A blood (for gastric ulcer) and type O blood (for duodenal ulcer). Other genetic factors or exposure to irritants. Cigarette smoking, psychogenic factors and stress and excessive alcohol consumption are common risk factors. Gastric ulcers are most common in middle-aged and elderly males, especially those who are poor and undernourished; prevalence higher in chronic users of aspirin or alcohol. Duodenal ulcers are most common in males ages 20 to 50.

ASSESSMENT

HISTORY ã…¡ Periods of symptom exacerbation and remission, with remissions lasting longer than exacerbations. History of predisposing factor. Left epigastric pain described as heartburn or indigestion, accompanied by feeling of fullness or distention. Gastric ulcer characterized by recent weight or appetite loss, nausea or vomiting and pain triggered or worsened by eating. Duodenal ulcer characterized by pain relieved by eating; may occur 1½ to 3 hours after food intake, pain that awakens the patient from sleep and weight gain.

PHYSICAL FINDING ã…¡ Pallor, epigastric tenderness, hyperactive bowel sounds. Complications of peptic ulcer includes GI hemorrhage, abdominal or intestinal infarction and ulcer penetration into attached structures.

DIAGNOSIS

LABORATORY TESTS ã…¡ Complete blood count shows anemia, occult blood is present in stools, venous blood sample shows H. pylori antibodies, white blood cell count is elevated, urea breath test shows low levels of exhaled carbon 13 (13C) and fasting serum gastrin level rules out Zollinger-Ellison syndrome.

IMAGING ã…¡ Barium swallow or upper GI and small-bowel series may reveal the ulcer, upper GI tract X-rays reveal mucosal abnormalities. Diagnostic procedures include upper GI endoscopy or esophagogastroduodenoscopy confirm the ulcer and permit cytologic studies and biopsy to rule out H. pylori or cancer and gastric secretory studies show hyperchlorhydria.

MANAGEMENT

GENERAL ã…¡ Iced saline lavage, possibly containing norepinephrine, stress reduction, smoking cessation, avoidance of dietary irritants, nothing by mouth if GI bleeding evident.

MEDICATIONS ã…¡ Eradicate if (+) H. pylori infection (see Table 1).

Table (1). Management of H. pylori –associated acid peptic disease (14 DAY)
Drug Class Drug Triple Therapy Dose Quadruple Therapy Dose Sequential Therapy Dose
Acid suppression Proton pump inhibitor (PPI) 20-40 mg BID 20-40 mg BID 20-40 mg BID
Standard antimicrobials Bismuth compound 2 tablets BID 2 tablets BID
Amoxicillin 1 g BID 1 g BID
Metronidazole 500 mg BID 500 mg TID 500 mg BID
Clarithromycin 500 mg BID 500 mg BID
Tetracycline 500 mg QID
Salvage antimicrobials Levofloxacin 300 mg BID 300 mg BID
Doxycycline 100 mg BID
Nitazoxanide 1 g BID
PPI = proton pump inhibitor, BID = Twice daily, QID = 4 times daily, TID = 3 times daily

NOTES
  • Triple therapy: consists of a proton pump inhibitor or bismuth compound, together with two of the listed antibiotics, usually given for 7-14 days. 
  • Quadruple therapy: consists of a proton pump inhibitor plus either the combination of a bismuth compound, metronidazole, and tetracycline given for 4-10 days, or the combination of levofloxacin, doxycycline, and nitazoxanide for 10 days. 
  • Sequential therapy: consists of 10 days of proton pump inhibitor treatment, plus amoxicillin during days 1-5 and a combination of clarithromycin and an imidazole (when available, tinidazole; otherwise, metronidazole) during days 6-10. 
  • Medications 
      • Proton pump inhibitor (omeprazole, pantoprazole, esomeprazole, lansoprazole, rabeprazole).
      • An alternative to metronidazole is tinidazole 500 mg BID.
      • Add PPI to decrease acid secretions.

REFERENCES

Abdelwahab Ward, BS Pharm, PharmD