Peptic Ulcer Treatment Question and Answers

Question. Write short note on peptic ulcer.

Or
Write short note on diagnosis and treatment of peptic ulcer.
Or
Write in detail about peptic ulcer and its management.

Answer. Peptic ulcer is defined as mucosal ulceration near the acid-bearing regions of the gastrointestinal tract. It is the ulcer in the duodenum and stomach.

Read And Learn More: General Medicine Question And Answers

Etiology of peptic ulcer

• Hereditary: Patient with blood group O has much incidence.
• H.pylori: Gram­negative bacteria are supposed to be the main cause accounting for 70% of gastric ulcers.
• NSAIDs: They lead to 30% of gastric ulcers. By depleting mucosal prostaglandin levels aspirin and NSAIDs impair cytoprotection resulting in mucosal injury, erosion, and ulceration
• Smoking: It does not cause ulcer but more likely to cause complication and is responsible for nonhealing or delayed healing.
• Corticosteroids: They are responsible for silent perforation of ulcer.
• Acid-pepsin versus mucosal resistance: Cause of peptic ulceration is digestion of the mucosa with acid and pepsin of gastric juice.
• A normal stomach is capable of resisting this digestion.
• So, the concept of peptic ulceration is acid plus pepsin versus mucosal resistance.
  • Factors that tilt this balance lead to the production of ulcers, The factors are:
    • Gastric hypersecretion.
    • Severe ulceration occurs in Zollinger­Ellison syndrome, which is characterized by very high acid secretion.
    • Acid secretion is more important in the etiology of duodenal ulcers than in gastric ulcers.
  • Factors reducing mucosal resistance:
    • Several drugs, particularly those used in rheumatoid arthritis.
    • Aspirin is an important etiological factor in gastric ulcers.
    • The organism Helicobacter pylori
    • Reflux of bile and intestinal contents into the stomach due to poorly functioning pyloric sphincter.
    • Other risk factors are smoking and alcohol consumption.

Clinical Features Peptic Ulcer

• The patient presents with recurrent abdominal pain which consists of three characteristics, i.e. localization of epigastrium, relationship to food, and periodicity.
• Patient has epigastric pain.
  • Pain is very sharply localized in the manner that the patient localize the site with one figer only.
  • This is also known as a pointing sign.
  • In its character, the pain is burning.
• Hunger pain: As a person remains empty stomach pain gets started which is relieved only by taking the food.
• Night pain: Patient wakes from the sleep due to the pain at around 3 AM. This is relieved by taking the food, milk or antacid.
• Periodicity of pain
  • Pain usually occurs in episodes and lasts for 1 to 3 weeks every time for 3 to 4 times a year. In between the episodes, patients become asymptomatic.
  • Initially, episodes are short in duration and are less frequent. With time episodes get longer in duration and their frequency increases.
  • In winter and spring seasons patients remain more symptomatic.
  • In smokers, relapse is more common as compared to non­smokers.

Investigations/ diagnosis of peptic ulcer

• Endoscopy: It is the ideal method of diagnosing. The ulcer appears as a severe aphthous ulcer with a creamy base.
• Barium meal: Peptic ulcer is seen in the form of a crater along the lesser curvature.
• Gastric acid secretion tests: A fractional test meal is done in which a gruel meal is given to stimulate gastric secretion.
  Both free and total acidity are estimated. Augmented histamine test is more specific and is used.
• Test for H. pylori: It consists of invasive and non­invasive
  tests:
  • Invasive tests
    • Rapid urease test
    • Histology
    • Culture
  • Non­invasive tests
    • Serology
    • Urea breath test

Treatment of peptic ulcer

Treatment of peptic ulcers is mainly medical.

• General measure:
  • Stop smoking
  • Stop NSAIDs, corticosteroids and alcohols
  • Avoid stress.
•  Pharmacotherapy:
  • Short term treatment
    • Antacids and alginates: These are the antacids that are the combination of aluminum and magnesium compounds, i.e. aluminum hydroxide, magnesium trisilicate, and alginic acid.
      These drugs form a protective mucosal raft.
      Sodium bicarbonate is the quickest-acting antacid.
      Its dose is 15 to 30mL liquid antacid 1 to 3 hours after the food and at bedtime for 4 to 6 weeks.
    • H2 receptor antagonists: i.e. ranitidine 150 mg BD or 300 mg at night; Famotidine can be given 20 mg BD or 40mg at night. In gastric ulcers dose should be given for 6 weeks followed by an endoscopy.
    • Proton pump inhibitors are given, i.e. omeprazole or rabeprazole 20 to 40 mg/day; pantoprazole 40mg/day and lansoprazole 15 to 30mg/day is given.
      These should be given for 4 to 8 weeks.
      Drugs omeprazole and lansoprazole should be given 30 minutes before taking a meal.
    • Prostaglandin analogue: Misoprostol 200 mg QDS helps to prevent NSAID-induced mucosal injury.
    • Colloidal bismuth compounds: Here drugs such as bismuth subsalicylate and colloidal bismuth subcitrate are given.
    • Complex salts: Sucralfate forms the protective covering for the ulcers.

H. pylori eradication

• Here triple drug therapy is used. The regimen includes two antibiotics and a proton pump inhibitor
• Commonly given regimen consists of amoxicillin l gm twice daily along with clarithromycin 500 mg twice daily with twice a day proton pump inhibitor, i.e. omeprazole or rabeprazole 20 mg, lansoprazole 30 mg, pantoprazole 40 mg for 14 days. If a person is allergic to penicillin, metronidazole may be used
  in place of amoxicillin.
• If the infection persists after giving triple therapy, quadruple therapy, i.e. proton pump inhibitor, bismuth, tetracycline, metronidazole is given.

Long-term treatment

•  Intermittent treatment
  • This should be given in cases where symptomatic relapses are less than 4 times a year.
  • A week’s course of one of the ulcer healing agents is given.
• Maintenance treatment
  • Continuous maintenance treatment is not needed after successful H. pylori eradication.
  • In the minority who do require it, the lowest effective dose should be given.
  • Long­term maintenance is with H2 receptor antagonists, i.e. cimetidine 400 mg at night,
    ranitidine l50 mg at night, famotidine 20 mg at night or nizatidine l50 mg at night.
• Surgical treatment
  • In cases with gastric ulcers, partial gastrectomy with a Billroth I anastomosis is the procedure of choice, in which the ulcer itself and ulcer-bearing area of the stomach are resected.
  • Duodenal ulcer treatment could be truncal vagotomy along with pyloroplasty or gastroenterostomy.
  • In the emergency condition, ‘under­running’the ulcer for bleeding or ‘over sewing’, i.e. patch repair for perforation is all that is required, in addition to taking a biopsy.
  • In patients with giant duodenal ulcers, partial gastrectomy using a ‘Polya’ or Billroth II reconstruction may be required.
  • Elective surgery is done in gastric outflow obstruction and recurrent ulcer despite the medical treatment.