PEPTIC ULCER

Fauzi Yusuf
Gastroenterohepatologi Division Internal Medicine Department Syiah Kuala University/Zainoel Abidin Hospital

PEPTIC ULCER

Incidens in Western Contries: Female 4 15 % & Male 10 15 % Patient Problem: Suffer recurrency / relaps, loss in the works, cost of medication expensive Upper GI endoscopy in Cipto Mangunkusumo Hospital: The incidene of Peptic Ulcer: 6,93 7,10%; Duodenal Ulcer: Gastric Ulcer = 2:1

Common Causes of Death in U.S.

9

Death per 100,000

8 7 6 5 4 3 2 1 0
Leukemia AIDS NSAID-GI disease Melanoma Asthma Cervical cancer

Wolfe et al. NEJM 1999

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

RSCM (1994)
28

RSUZA (2001/2002)
17,5

Gastritis/erosive Gastritis
Duodenitis Esophagitis Bile Reflux Gastritis

44,67
7,67 5,83 4,5

40,5
7,05 10,70 1,05

Duodenal Ulcer Gastric Ulcer

Portal Hypertensive gastropathy Gastric Tumor Others

3,5 2,2
1,2 1 3,16

2,037 1,05
3,05 0,95 0,024

DEFINITION

Peptic Ulcer: Damage of mucosal layer/muscularis mucosa or deeper until submucosa of the stomach/duodenum, ulcer edge surounded by acute and chronic inflamatory cells; the diameter 5 mm Erosion: damage < 5 mm and the depth not over than muscularis mucosa

BALANCE THEORY SHAY & SUN

Ulcer
Healing
Aggressive Factor Defensive Factor Mucus, mucin Fosfolipida Ion bicarbonat Prostaglandin Mucous blood flow Cell regeneration BALANCE Shay & Sun

Acid Pepsin Food Alcohol NSAIDs H. pylori

Differences between NSAID and H.pylori induced ulcers

NSAIDs induced
Patients demographics Elderly more than young Women more often than men Gastric more than duodenal More often asymptomatic Surrounding mucosa normal (foveolar hyperplasia)

H.pylori
Young more often than elderly Men more often than woman Duodenal more than gastric Usually pain and or dyspepsia Surrounding mucosa inflammed (active chronic gastritis)
Scarpignato,1997

Site of damage Symptoms Histology

Risk Factors for NSAIDs Induced Gastroduodenal Ulceration

Established
Advanced age History of ulcer Concomitant use of glucocorticoids High-dose NSAIDs Multiple NSAIDs Concomitant use of anticoagulants Serious or multisystem disease

Possible
Concomitant infection with Cigarette smoking Alcohol consumption

H. pylori

Pathogenesis of NSAID-induced ulcers

PROTECTIVE FACTORS
Prostaglandins

AGGRESSIVE FACTORS

Acid + pepsin
Mucus layer Bicarbonate Surface epithelial cells Mucosal blood supply

H. pylori

Seager & Hawkey, BMJ 2001; 323: 12369.

Pathogenesis of NSAID-induced ulcers

PROTECTIVE FACTORS
Prostaglandins

AGGRESSIVE FACTORS

NSAIDs

Acid + pepsin

H. pylori

Mucus layer
Bicarbonate

Surface epithelial cells

Mucosal blood supply

Seager & Hawkey, BMJ 2001; 323: 12369.

Peptic Ulcer Clinical Manifestation

1. History of illness

None Dyspeptic Symptom: Epigastric Pain, Nausea, Vomiting,anorexia, epigastric discomfort, etc Epigastric Pain Episodic, Nocturnal, Pain-Food- Relief pattern can be pointed at Loss of body weight Hematemesis and Melena

Peptic Ulcer Clinical Manifestation (Cont)

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

Diagnosis of Helicobacter Pylori Infection

NON-INVASIVE

Urea Breath Test Serum serology for Hp antibody test Whole blood serology for Hp antibody test Saliva Assay for Hp antibody test Helicobacter Pylori stool antigent (HpSA) test

INVASIVE (biopsy & endoscopy)

Culture test Histopatology test Urease test PCR

MANAGEMENT

General/supportif Stop/Inhibit aggressive factor Increase the defensive factor Other treatment Threat the complication Avoid ulcer relaps/recurrence

Indication of Upper Gastrointestinal/ Esophago-gastro-duodenoscopy

Age over 45 years old Alarm signs Therapy failure History of Peptic ulcer + Complication Patient enquery The use of aspirin or NSAID Abnormality in Upper GI X-Ray (OMD)

H Pylori Eradication (KSHPI)

Tripple therapy (1 or 2 weeks): PPI + Amoxicillin + Clarithromycin PPI + Metronidazole + Clarithromycin PPI + Metronidazole + Tetracyclin (Alergy to clarithromycin) Quadrupple therapy ( 1 or 2 weeks): If fail to therapy combination 3 drugs:

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

High resistency area: PPI + Bismuth + Tetracyclin + Metronidazole PPI 2 x/d: Omeprazole/Esomeprazole 20 mg, Lansoprazole 30 mg, 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 4 x 120 mg/d

CONCLUSIONS

The three aims of ulcer treatment are : Symptom relief, Healing of the ulcer, prevention of recurrence. For H Pylori Positive, Eradication therapy should be given to prevent ulcer recurrence For optimal ulcer healing, NSAIDS should be stop is possible.