1. Treatment for Upper GI bleeding due to PUD

2. Goals Control upper GI bleeding Provide symptom relief Promote ulcer healing Prevent recurrence and other complications

3. Peptic Ulcer Bleeding Common medical emergency; 300,000 hospital admissions in the US. Predominant among the elderly 80-85% UGI bleeding stops spontaneously 15-20% continues or develops into recurrent bleeding Sung, J(2006).Current Management of Peptic Ulcer Bleeding. Journal on Nature Clinical Practice of Gastroenterology and Hepatology. Ret. http://www.medscape.com/viewarticle/521189

4. Endoscopic Therapy Injection Therapy – Injection with diluted epinephrine (1:10,000) – Tamponade effect Thermal devices – heater probe, monopolar and bipolar electrocoagulation Mechanical devices – Hemoclips Sung, J(2006).Current Management of Peptic Ulcer Bleeding. Journal on Nature Clinical Practice of Gastroenterology and Hepatology. Ret. http://www.medscape.com/viewarticle/521189

5. Pharmacologic Mgt for Bleeding PUD Antisecretory Agents Proton Pump Inhibitors H2 receptor antagonists

6. Antisecretory Agents Proton Pump Inhibitors – Irreversibly inhibit gastric parietal cell proton pump H+/K+-ATPase. – Inhibit both fasting and meal stimulated secretion  Blocks the final common pathway of acid secretion Omeprazole 20 mg bid 4-8 weeks or IV Omeprazole

7. Lau et al – a high-dose omeprazole infusion (80 mg intravenous bolus followed by 8 mg per hour for 72 h) or an equivalent of placebo – rate of recurrent bleeding at day 30 was 21.7% and 5.8%, respectively, for those assigned to placebo and omeprazole infusion. reduction in the need for re-treatment and blood transfusion trend towards fewer surgeries and deaths among those assigned to omeprazole infusion Sung, J(2006).Current Management of Peptic Ulcer Bleeding. Journal on Nature Clinical Practice of Gastroenterology and Hepatology. Ret. http://www.medscape.com/viewarticle/521189

8. Proton Pump Inhibitors for H. Pylori-induced PUD Mechanisms: Direct antimicrobial properties(minor) Raising intragastric pH – Lowering minimal inhibitory concentrations of antibiotics against H.Pylori

9. Antisecretory Agents Proton Pump Inhibitors Adverse effects: – Subnormal B12 levels with prolonged therapy – Increased gastric bacterial concentration – Increases chronic inflammation of gastric body – Small benign gastric fundic gland polyps

10. Antisecretory Agents H2 receptor antagonist – Competitive inhibitors of the action of Histamine at H2 receptors in the parietal cells.

11. Antisecretory Agents H2 receptor antagonists – Cimetidine – Famotidine 20 mg BID – Ranitidine 150 mg tab BID

12. Algorithm on Treatment of UGI Bleeding

14. Treatment Regimen for H.Pylori Triple TherapyQuadruple Therapy Omeprazole (20 mg bid) Omeprazole (20 mg bid) Omeprazole (20 mg bid) Clarithromycin (500 mg bid) Bismuth Subcitrate (2 tab qid) Amoxicillin (1 g bid) Metronidazole (500 mg bid) Metronidazole (250 mg tid) Tetracycline (500 mg qid)

15. Other Drugs used for PUD

16. Antacids Aluminum Hydroxide Magnesium Hydroxde Sodium Bicarbonate Mechanisms: – Reduction of intragastric acidity – Stimulation of mucosal prostaglandin production Promote mucosal defense

17. Mucosal Protective Agents Bismuth Subcitrate – Selective binding to an ulcer, coating and protecting from acid and pepsin – Inhibition of pepsin activity; stimulation of mucus production; increase PG synthesis

18. Mucosal Protective Agents Sucralfate – Forms a viscous, tenacious paste that binds to the ulcer or erosion forming a PHYSICAL BARRIER – 1 g qid ; 1 hour before meals

19. Prostaglandin Analogs Misoprostol – prostaglandin E1 analogue which acts as natural prostaglandin in the body – Only indicated for prevention of NSAID induced gastric ulcers in high risk patients. – causes spontaneous abortion Side effects diarrhea and crampy abdominal pain