Diagnosis of PUD

Barium Studies Still commonly used as a first test for documenting an ulcer 80% sensitivity : single contrast barium study 90% sensitivity: double contrast barium study Sensitivity is low for small ulcers (<0.5 cm) Duodenal ulcers appear as a well demarcated crater most often seen at the bulb Gastric ulcers may either be benign or malignant

Barium Studies Benign gastric ulcer appears as a discrete crater with radiating mucosal folds originating from the mucosal margin Ulcers >3 cm are more often malignant Radiographic studies that show a gastric ulcer must be followed by endoscopy and biopsy. Fauci, et. al. Harrison’s Principles of Internal Medicine, 17 th ed.

Endoscopy Most sensitive and specific Direct visualization of the mucosa Photographic documentation of the defect Tissue biopsy to rule out malignancy or H. pylori. Helpful in identifying lesions too small to detect by radiographic examination, evaluation of atypical radiographic abnormalities, or to determine if an ulcer is a source of blood loss Fauci, et. al. Harrison’s Principles of Internal Medicine, 17 th ed.

Detection of H. pylori NON-INVASIVE Serology Urea Breath Test Detection of antibodies in the serum Urea Breath Test Simple, rapid, early follow up Stool antigen Sensitive, specific, and inexpensive Fauci, et. al. Harrison’s Principles of Internal Medicine, 17 th ed.

Detection of H. pylori INVASIVE (Endoscopy/Biopsy required) Rapid urease Simple, false negative with recent use of PPIs, antibiotics, or bismuth compounds Histology Provides histologic information Culture Time-consuming, expensive Fauci, et. al. Harrison’s Principles of Internal Medicine, 17 th ed.

Treatment of PUD

Objectives Pain relief Healing Prevention of complications Prevention of recurrences

Antacids Rarely used as a primary therapeutic agents but are instead used for symptomatic relief Mixture of aluminum hydroxide and magnesium hydroxide Eg. Maalox, Mylanta Fauci, et. al. Harrison’s Principles of Internal Medicine, 17 th ed.

H2 Receptor Antagonists Inhibit basal and stimulated acid secretion Often used for treatment of active ulcers (4-6 weeks) in combination with an antibiotic directed at eradicating H. pylori. Eg. Cimetidine, Ranitidine, Famotidine, Nizatidine Fauci, et. al. Harrison’s Principles of Internal Medicine, 17 th ed.

Proton Pump Inhibitors Substituted benzimidazole derivatives that covalently bind and irreversibly inhibit H+K+-ATPase Eg. Omeprazole, Esomeprazole, Lansoprazole, Rabeprazole, Pantoprazole Fauci, et. al. Harrison’s Principles of Internal Medicine, 17 th ed.

Cytoprotective Agents Sucralfate Insoluble in water Viscous paste within the stomach and duodenum, binding primarily to sites of active ulceration Bismuth-containing compounds Ulcer coating; prevention of further pepsin/HCl-induced damage; binding of pepsin; and stimulation of PGs, bicarbonate, and mucous secretion Prostaglandin Analogues Enhancement of mucosal defense and repair Eg. Misoprostol Fauci, et. al. Harrison’s Principles of Internal Medicine, 17 th ed.

THERAPY FOR H. pylori Eradication of H. pylori is the primary goal DRUG DOSE TRIPLE THERAPY Bismuth subsalicylate plus Metronidazole plus Tetracycline Ranitidine bismuth citrate plus Tetracycline plus Clarithromycin or Metronidazole Omeprazole (lansoprazole) plus Clarithromycin plus Metronidazole or Amoxicillin 2 tabs qid 250 mg qid 500 mg qid 400 mg bid 500 mg bid 20 mg bid (30 mg bid) 250 or 500 mg bid 1 g bid

Bismuth subsalicylate Metronidazole Tetracycline 20 mg (30 mg) daily DRUG DOSE QUADRUPLE THERAPY Omeprazole Bismuth subsalicylate Metronidazole Tetracycline 20 mg (30 mg) daily 2 tablets qid 250 mg qid 500 mg qid Fauci, et. al. Harrison’s Principles of Internal Medicine, 17 th ed.