​Kembara Xtra - Medicine - Peptic Ulcer Disease

​Kembara Xtra - Medicine - Peptic Ulcer Disease 
Peptic ulcer disease is defined by abnormalities in the stomach and/or duodenal mucosa, which allow gastric acid and pepsin to cause inflammation of the underlying tissue.
The most prevalent type of peptic ulcer is a duodenal ulcer, which is often seen in the proximal duodenum. The likelihood of gastrinoma (Zollinger-Ellison syndrome) is increased by multiple ulcers or ulcers distal to the second portion of the duodenum and/or jejunum.
In the absence of NSAID use, gastric ulcers are less common than duodenal ulcers and are frequently found along the smaller curvature of the antrum.  Gastrinoma and gastroesophageal reflux disease (GERD) are both conditions that can cause esophageal ulcers, which are found in the distal esophagus. Ectopic gastric mucosal ulceration: Meckel diverticulum is a risk factor.

Men are more likely than women to get ulcers, and between the ages of 25 and 64, 70% of cases occur.
- The incidence of duodenal/gastric ulcers rises with age.
Peptic ulcers occur in 500,000 new cases and 4 million recurrences per year, with a global incidence rate of 0.1-0.19%.

Prevalence

10% of the population as a whole
In patients with Helicobacter pylori positivity, the lifetime prevalence is higher (10–20%) than in the general population (5–10%).
In high-income nations like the United States, peptic ulcer disease incidence and prevalence have reduced.


Pathophysiology and Etiology 
Genetics Familial clustering of H. pylori infection and inherited genetic variables reflecting the organism's response are likely the causes of the increased frequency of PUD in families.

Risk Elements 
Chronic use of NSAIDs, including aspirin and COX-2 inhibitors; H. pylori infection (95% of duodenal and 70% of stomach ulcers). Regular users of NSAIDs have been reported to also have an H. pylori infection.
Smoking Stress (including acute illness, ventilator support, severe burns, and head injuries)   Gastrinoma (Zollinger-Ellison), systemic mastocytosis, carcinoid disease, and alcohol usage are hypersecretion syndromes.  Medications: clopidogrel, potassium chloride, bisphosphonates, sirolimus, and corticosteroids (high-dose and/or extended therapy). Radiation treatment

Basic Prevention 

NSAID ulcers: If a patient has previously experienced an ulcer caused by an NSAID, they should stop using NSAIDs and switch to acetaminophen or add a proton pump inhibitor (PPI). Use the lowest dose of NSAIDs possible and combine them with a PPI or misoprostol if they are absolutely necessary.
- Consider detecting and eliminating H. pylori to lower the chance of developing ulcers.
Patients with a history of ulcer complications, recurrences, refractory ulcers, or persistent H. pylori infection should get maintenance therapy with PPIs or H2 blockers.
In patients with H. pylori-negative, non-NSAID-induced ulcers, consider maintenance PPI therapy.
- Infection with H. pylori is present in 95% of duodenal ulcers and 70% of stomach ulcers. Individuals with this infection have a 1% annual chance of developing a duodenal ulcer.


Accompanying Conditions 
Carcinoid syndrome, Multiple Endocrine Neoplasia Type 1, Gastrinoma (Zollinger-Ellison syndrome),
Hematopoietic illnesses (rare) include systemic mastocytosis, myeloproliferative disease, hyperparathyroidism, and polycythemia rubra vera. Chronic diseases include Crohn's disease, chronic obstructive pulmonary disease (COPD), chronic renal failure, hepatic cirrhosis, and cystic fibrosis.

A duodenal ulcer is the most likely diagnosis. Signs and symptoms include: - Midepigastric pain; - Gnawing or burning; - Recurrent; - Often episodic; - Relieved by food or antacids.
- A stomach ulcer
Midepigastric discomfort is a recurrent, nonradiating, gnawing or burning sensation that is frequently episodic.  Made worse by food, made better by antacids
Non-specific dyspeptic symptoms include indigestion, nausea, vomiting, weight loss, heartburn, and a feeling of fullness in the stomach.  Alarming or red flag symptoms
- After age 55, the onset of symptoms
- Progression of the dysphagia
- Hematemesis, melena, blood in the stool, and anemia
Weight loss, anorexia, or a family history of stomach cancer NSAID-induced ulcers are frequently silent; bleeding or perforation may be the initial presenting symptom.

clinical assessment 
may not be precise Examine your vital signs for hemodynamic stability, conjunctival pallor (anemia), and epigastric discomfort, which is absent in at least 30% of older individuals. stool guaiac-positive due to hidden blood loss

Multiple Diagnoses 
Functional dyspepsia, gastritis, GERD, biliary colic, gastroenteritis, pancreatitis, cholecystitis, Crohn's disease, intestinal ischaemia, heart ischaemia, and gastrointestinal cancer

Initial test results from the laboratory and imaging
Lab tests to think about:
- CBC: Don't include anemia.
- Occult blood test for feces
- Tests of liver function
the Lipase
- Testing for H. Pylori
- To rule out gastrinoma in cases of many or resistant ulcers, consider fasting serum gastrin.
 Reasons to test for H. pylori include: Gastric mucosa-associated lymphoid tissue (MALT) lymphoma, newly diagnosed PUD, a history of PUD, persisting symptoms despite empiric antisecretory medication, and undiagnosed dyspepsia in patients under 50 without alarm signs H. pylori diagnostic procedures - Patients who have active bleeding, those who have recently taken bismuth, PPIs, or antibiotics may experience false-negative results.
Noninvasive examinations
 For at least 4 weeks, stop using bismuth and antibiotics, and give up PPIs for a week before testing.
Stool antigen has a strong positive and negative predictive value (sensitivity, 87%; specificity, 70%); patients may not wish to collect stool. It can be used for screening and posttreatment testing. The urea breath test can be used for screening and post-treatment testing and can detect active infections. It has a good positive and negative predictive value (sensitivity: 93%; specificity: 92%) but is not always available and is not always covered by insurance. Serology is a cheap test that can only be conducted on untreated patients and cannot be used to prove an infection has been eradicated (sensitivity: 88%; specificity: 69%). invasive examinations
 Upper endoscopy has the highest sensitivity and specificity for detecting PUD and active H. pylori infection. Only individuals who exhibit "red flag" symptoms should undergo an endoscopy because it is pricy and intrusive (1)[B].
 Gastric biopsies were subjected to a rapid urease test (sensitivity: 93–97%; specificity: 95%). When endoscopy is neither appropriate or practical, barium or gastrografin contrast radiography (double-contrast hypotonic duodenography) is recommended. Diagnostic Techniques / Other
 Upper endoscopy has the highest sensitivity and specificity for detecting PUD and active H. pylori infection. Only individuals who exhibit "red flag" symptoms should undergo an endoscopy because it is pricy and intrusive (1)[B].
 Gastric biopsies were subjected to a rapid urease test (sensitivity: 93–97%; specificity: 95%).

First Line of Medicine

PPIs are more effective at suppressing acid than H2 blockers. On PPI medication, 95% of duodenal ulcers recover within 4 weeks.
Omeprazole 20 mg orally daily, lansoprazole 30 mg orally daily, rabeprazole 20 mg orally daily, esomeprazole 40 mg orally daily, pantoprazole 40 mg orally daily, and dexlansoprazole 30 mg orally daily.
Treatment lasts 4 to 8 weeks.
Blockers of H2
 Cimetidine 400 mg PO BID or 800 mg PO at bedtime; famotidine 20 mg PO BID or 40 mg PO at bedtime; ranitidine or nizatidine 150 mg PO BID or 300 mg PO. Treatment lasts 4 to 8 weeks.
Precautions: If CrCl is less than 50 mL/min, reduce H2 blocker dosage by 50%.
PPIs might lower bone density. With long-term PPI use, get interval bone densitometry (2).
PPIs could lead to hypomagnesemia.
- PPIs may raise the chance of contracting Clostridium difficile infection.
- Despite previous worries, PPIs do not appear to reduce the efficacy of clopidogrel. - Short-term PPI usage connected with development of community-acquired pneumonia; long-term use does not appear to have an increased risk.
NSAID-associated ulcers
- Stop using NSAIDs. - Treat with PPIs for 4 to 8 weeks; use as maintenance in patients with complicated, recurring, or idiopathic ulcers; or in patients who need to take aspirin or NSAIDs for an extended period of time.
H. pylori-induced ulcers and H. pylori treatment protocols
14-day course of clarithromycin-based triple therapy: normal dosage PPI PO BID plus amoxicillin 1 g PO BID plus clarithromycin 500 mg PO BID
14-day bismuth-based quadruple therapy: recommended dosage PPI PO BID plus 500 mg of clarithromycin PO BID plus 1 g of amoxicillin PO BID
 Standard dose of metronidazole for patients with amoxicillin allergies PPI Clarithromycin 500 mg PO BID in addition to 500 mg PO BID of metronidazole
Sequential therapy: usual dosage PPI PO BID plus 1 g of amoxicillin PO BID for 5 days, then PPI PO BID plus 500 mg each of clarithromycin and tinidazole for 5 days. 

Next Line
For the elimination of H. pylori: If first-line therapy is unsuccessful, switch to second-line therapy: - 14 days of bismuth triple therapy
525 mg of Bismuth Subsalicylate PO QID in addition
Metronidazole 250mg PO QID in addition
Tetracycline 500 mg PO QID in addition to the standard dosage PPI PO BID - Yet another salvaging alternate therapy
PPI orally BID, plus 1,000 mg of Amoxicillin PO BID and 300 mg of Rifabutin PO daily.
Alternative medicines for treating ulcers:
- Antacids and sucralfate
Important potential interactions
- Avoid using cimetidine with theophylline, warfarin, phenytoin, and lidocaine as they inhibit cytochrome P450 isozymes.
- Omeprazole may delay the clearance of phenytoin, warfarin, and diazepam.
- Tetracycline, norfloxacin, ciprofloxacin, and theophylline's absorption is decreased by sucralfate, resulting in subtherapeutic levels.
pregnant women's issues
PPIs do not raise the risk of serious birth abnormalities, spontaneous abortions, or preterm birth. Breastfeeding: Ranitidine and esomeprazole are both secreted at far lower quantities in breast milk than they are when used to treat infants with reflux disorder. Use in nursing mothers is often safe.
QUESTIONS FOR REFERENCE
Red flag symptoms should prompt an endoscopic referral:
Onset of symptoms after the age of 55; progressive dysphagia; recurrent vomiting; melena; hematemesis; anemia; progressive dysphagia; persistent/recurrent vomiting; severe abdominal pain; weight loss; anorexia; or a family history of gastric cancer. 

Surgery Patients over the age of 55 with newly developing dyspeptic symptoms, those who do not respond to treatment, and patients of any age with alarm/red flag symptoms should have endoscopy.
- A stomach biopsy is taken during endoscopy to test for H. pylori (CLO test). - Biopsy the ulcer margin to rule out cancer
- Epinephrine injection, heating probe treatment, or the insertion of endoscopic clips are interventions to halt active bleeding or prevent rebleeding in patients with certain stigmata.
Because ulcers and H. pylori infection are well treated medically, surgery is rarely necessary when an ulcer perforates.
Non-emergent surgical indications include bleeding that is unresponsive to endoscopic treatments and patients at high risk for complications (such as transplant recipients and those who are dependent on steroids or NSAIDs). Surgical possibilities
- Truncal vagotomy and drainage (pyloroplasty/gastrojejunostomy), selective vagotomy and drainage (keeping the hepatic and/or celiac branches of the vagus), or extremely selective vagotomy are all options for treating duodenal ulcers.- Perforated ulcers: laparoscopy/open patching - Gastric ulcers: partial gastrectomy, Billroth I or II - Emerging options: Vonoprazan is a new acid blocker that is noninferior to PPIs.

Admssion
Stop using ulcer-causing medications, such as NSAIDs.
 Peptic ulcers that are bleeding
- Stable: Administer PPI to shorten hospital stays, avoid the need for surgery, and reduce transfusion needs.
Unstable: fluid/packed RBC resuscitation, then urgent esophagogastroduodenoscopy (EGD) or surgery; utilize IV PPI.
- There is insufficient proof that high-dose PPI therapy reduces peptic ulcer bleeding compared to lesser dosages.
After endoscopic treatment, oral PPI is comparable to IV, and perforated peptic ulcers require immediate surgery.


Patient Follow-Up Monitoring
 Elimination of H. pylori is anticipated in >90% of cases (when receiving a double antibiotic treatment); confirm this with a urea breath test or a fecal antigen test.
Monitor a duodenal ulcer that is acute clinically.
 Acute gastric ulcer: Endoscopy after 12 weeks to confirm healing; biopsies (if not performed initially) to confirm benign mucosa

After H. pylori removal, there is a low risk of ulcer recurrence; in the event that it does, usage of NSAIDs or cigarettes should be considered.
Low risk of rebleeding; Reinfection rates of less than 1% year; Decreased NSAID Ulcer Recurrence


Complications 
Up to 25% of patients get hemorrhage (only 10% initially present). Perforation occurs in 5% of patients.
Males are more likely to develop duodenal or pyloric channel ulcers, which can cause gastric outlet obstruction. Patients with H. pylori infection also have an increased risk of developing stomach cancer.
 Refractory peptic ulcer disease (5–10% following H. pylori eradication or completion of 12 weeks of PPI).

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