What is Peptic Ulcer Disease(PUD)?
Definition
Burning epigastric pain exacerbated by fasting and improved with meals is a symptom complex associated with peptic ulcer disease(PUD).
An ulcer is defined as disruption of the mucosal integrity of the stomach and/or duodenum leading to a local defect or excavation due to active inflammation.
Ulcers occur within the stomach and/ or duodenum and less commonly in the esophagus, and rarely on the other portions of small intestine and are often chronic in nature.
PUD encompasses both gastric and duodenal ulcers. Ulcers are defined as breaks in the mucosal surface >5 mm in size, with depth to the submucosa.
Duodenal ulcers (DUs) and gastric ulcers (GUs) share many common features in terms of pathogenesis, diagnosis, and treatment, but several factors distinguish them from one another.
Helicobacter pylori and NSAIDs are the most common risk factors for PUD.
CLINICAL FEATURES OF PUD
Abdominal pain is common to many GI disorders, including DU and GU, but has a poor predictive value for the presence of either DU or GU. Up to 10% of patients with NSAID-induced mucosal disease can present with a complication (bleeding, perforation, and obstruction) without antecedent symptoms.
Pain that awakes the patient from sleep (between midnight and 3 A.M.) is the most discriminating symptom, with two-thirds of DU patients describing this complaint.Unfortunately, this symptom is also present in one-third of patients with Non-Ulcer Dyspepsia(NUD).
Variation in the intensity or distribution of the abdominal pain,as well as the onset of associated symptoms such as nausea and/or vomiting, may be indicative of an ulcer complication. Dyspepsia that becomes constant, is no longer relieved by food or antacids, or radiates to the back may indicate a penetrating ulcer (pancreas). Sudden onset of severe, generalized abdominal pain may indicate perforation.
Pain worsening with meals, nausea, and vomiting of undigested food suggest gastric outlet obstruction.
Tarry stools or coffee-ground emesis indicate bleeding
Epigastric tenderness is the most frequent finding in patients with GU or DU.
Pain may be found to the right of the midline in 20% of patients. Unfortunately, the predictive value of this finding is rather low.
Physical examination is critically important for discovering evidence of ulcer complication.
Tachycardia and orthostasis suggest dehydration secondary to vomiting or active GI blood loss. A severely tender, board-like abdomen suggests a perforation.
Presence of a succussion splash indicates retained fluid in the stomach, suggesting gastric outlet obstruction.
PUD-REALTED COMPLICATIONS
1.GASTROINTESTINAL BLEEDING
2.PERFORATION
3.GASTRIC OUTLET OBSTRUCTION
4.STOMACH CANCER
Objectives of treatment:
• Relief of symptoms (pain, dyspepsia)
• Eradication of H. pylori to prevent recurrence
• Promote ulcer healing
TREATMENT OF PEPTIC ULCER DISEASE
ACID-NEUTRALIZING/INHIBITORY DRUGS
The most commonly used agents are mixtures of aluminum hydroxide and magnesium hydroxide.
H2 RECEPTOR ANTAGONISTS
Four of these agents are presently available (cimetidine, ranitidine, famotidine, and nizatidine), and their structures share homology with histamine.
PROTON PUMP (H+,K+-ATPase) INHIBITORS
Omeprazole, esomeprazole,lansoprazole, rabeprazole, and pantoprazole are substituted benzimidazole derivatives that covalently bind and irreversibly inhibit H+,K+-ATPase.
Two new formulations of acid inhibitory agents are being developed.A) Tenatoprazole B) potassium-competitive acid pump antagonists (P-CABs).
CYTOPROTECTIVE AGENTS
a). SUCRALFATE:Sucralfate is a complex sucrose salt in which the hydroxyl groups have been substituted by aluminum hydroxide and sulfate.
Sucralfate may act by several mechanisms:serving as a physicochemical barrier, promoting a trophic action by binding growth factors such as EGF, enhancing prostaglandin synthesis, stimulating mucus and bicarbonate secretion, and enhancing mucosal defense and repair.
b). Bismuth-Containing Preparations
Colloidal bismuth subcitrate (CBS) and bismuth subsalicylate (BSS, Pepto-Bismol) are the most widely used preparations.
The mechanism by which these agents induce ulcer healing is unclear.
These compounds are commonly used as one of the agents in an anti-H. pylori regimen.
Table: Drugs Used in the Treatment of Peptic Ulcer Disease
Comments
Post a Comment