1. Peptic Ulcer Diseae

2. Peptic Ulcer Diseae The term “peptic ulcer” refers to an ulcer in:
Lower esophagus
Stomach
Duodenum
Jejunum after surgical anastomosis to stomach
Rarely, ileum adjacent to Meckel’s diverticulum.
It may be acute or chronic
Both penetrate muscularis mucosae
Acute ulcer shows no evidence of fibrosis
Erosions do not penetrate muscularis mucosae

3. Other factors affecting
Peptic Ulcer Diseae
Etiology
Peptic Ulcer Disease
H. Pylori infection
NSAIDs
Smoking
Other factors affecting
Acid-pepsin versus
Mucosal resistance

5. Peptic Ulcer Diseae Pathology Chronic gastric ulcer:
It is usually single
90% are situated on the lesser curve within the antrum or at the junction between the body and antral mucosa
Chronic duodenal ulcer:
It usually occurs in the 1st part of the duodenum just distal to the junction of the pyloric and duodenal mucosa.
50% are on the anterior wall
Gastric & duodenal ulcers coexist in 10% of patients
More than one peptic ulcer is found in 10-15% of patients
Chronic ulcer shows 4 layers:
Surface debris
An infiltrate of neutrophils
Granulation tissue
Collagen

6. Peptic Ulcer Diseae Clinical Features
Natural history of spontaneous relapse & remission lasting for decades, if not for life.
Recurrent abdominal pain:
Localization to the epigastrium
Relationship to food
Episodic occurrence
Vomiting:
Occurs in 40% of cases
Persistent daily vomiting suggests gastric outlet obstruction.
In 1/3rd of patients the history is less characteristic particularly in elderly especially those under treatment with NSAIDs
Occasionally, the only symptom is:
Anorexia & nausea
Sense of undue repletion after meals

7. Peptic Ulcer Diseae Clinical Features
In some patients the ulcer is completely silent and the patients present for the 1st time with;
Anemia from chronic undetected blood loss
Abrupt hematemesis
Acute perforation
In other patients, there is recurrent acute bleeding without ulcer pain between the attcks
It should be noted that:
The diagnostic value of individual symptoms for peptic ulcer disease is poor
The history is often a poor predictor of the presence of an ulcer.

8. Peptic Ulcer Diseae Diagnosis The diagnosis can be made by either:
Double contrast barium meal.
Endoscopy:
It is the preferred method because:
It is more accurate
Suspicious lesions and H. pylori status can be evaluated by biopsy.
For those with duodenal ulcer seen at barium meal, urea breath testing will accurately define H. pylori status.
Endoscopy & biopsy is mandatory when gastric ulcer is detected at barium meal because of the risk of being malignant.
In addition, repeated endoscopy examination is indicated in cases of gastric ulcer after suitable treatment.
It is not necessary to repeat the endoscopy in cases of treated duodenal ulcer as follow up tool

9. Fundus
Ulcer Creator
Radiating folds

10. Ulcer
Towards pylorus

11. Macroscopic features of gastric ulcer Radiating Mucosal folds

12. Deep duodenal
ulcer
Duodenal loop
Duodenal cup
Antrum of stomach

13. Duodenal ulcer

14. Multiple duodenal ulcers in case suspected to have Zollinger Ellison syndrome

15. Treatment of
Peptic Ulcer

16. Treatment of Peptic Ulcer
The aims of management are to:
Relieve symptoms
Induce ulcer healing in the short term
Cure the ulcer in the long term
H. pylori eradication is the cornerstone of therapy of peptic ulcer, as this will:
Prevent ulcer relapse and complications
Eliminate the need for long-term therapy in the majority of the patients.
Improve quality of life

17. H. pylori eradication Treatment of Peptic ulcer Surgical Treatment
General
measures
Maintenance
treatment
Short-term
management

18. H. pyolri Eradication Indications: Definite: Not indicated: Uncertain:
Peptic Ulcer
MALToma
Not indicated:
Asymptomatic
GERD
Uncertain:
Family history of gastric cancer
Non-ulcer dyspepsia
Long-term NSAIDs users

19. All three drugs for 7 days
H. pyolri Eradication
Antibiotic regimens:
First-line therapy including:
Proton pump inhibitor at standard dose (12 hourly) +
Amoxicillin 1 g 12-hourly
Clarithromycin 500 mg 12 hourly or
Metronidazole 400 mg 12-hourly
All three drugs for 7 days

20. All of the above FOUR drugs for 7 days
H. pyolri Eradication
Second-line therapy (recommended in case of failure of 1st line therapy):
Proton pump inhibitor in standard dose, 12-hourly
Bismuth 120 mg 6-hourly
Metronidazole 400 mg 12-hourly
Tetracycline 500 mg 6-hourly
All of the above FOUR drugs for 7 days

21. H. pyolri Eradication
Only 50% of peptic ulcer patients are treated
Only 50% receive adequate antibiotics

22. H. pyolri Eradication
Common side effects of H. pylori eradication therapy:
Diarrhea:
30-50% of patients, usually mild but Clostrdium deficille-associated colitis can occur
Metronidazole;
Metallic taste (common)
Peripheral neuropathy (rare)
Flushing & vomiting when taken with alcohol
Nausea, vomiting
Abdominal cramp
Headache
Rash

23. General Measures The patients should avoid:
Cigarette smoking
Aspirin & NSAIDs
Alcohol in moderation is not harmful
No special dietary advice is required.

24. Short-term management
Many different drugs are available for the short-term management of acid-peptic symptoms including:
Antacids:
Relieve minor dyspeptic symptoms
Calcium compounds cause constipation
Aluminium compounds cause:
Diarrhea
Block absorption of digoxin, tetracycline, & dietary phosphate
Most have high sodium content (can exacerbate CHF)

25. Short-term management
Histamine H2-receptor antagonist drugs
H+/K+ ATPase (proton pump) inhibitors
Colloidal bismuth compounds
Sucralfate
Synthetic prostaglandin analogues (misoprostol)

27. Maintenance Treatment
Continuous maintenance treatment should not be necessary after successful H. pylori eradication.
For the minority who require maintenance treatment, the lowest effective dose should be used.

28. Surgical Treatment Indications for surgery in peptic ulcer: Emergency:
Perforation
Hemorrhage
Elective:
Complications e.g. gastric outflow obstruction
Recurrent ulcer following gastric surgery

29. GU DU Re-endoscopy Healed Follow-up evaluation PU patients Non-Healed
Symptoms
relieved
Symptoms
persisting
Re-endoscopy
Non-Healed
(Biopsy)
Healed
1- Another diagnosis
2- Irritable Gut
Persisting
H. Pylori infection
Non-H. pylori ulcer

30. Causes of Refractory/Recurrent PU
Non-H. pylori ulcer:
False negative H. pylori
Inadequate biopsy
Proton pump inhibitor or Bismuth intake
Continues use of NSAIDs
Delayed healing
Dense fibrosis
Smoking
Big ulcer
Hypersecretory state
Non-peptic ulcer:
Tuberculosis
Cancer
Crohn’s disease
Persisting H. pylori infection:
Poor compliance
Resistant H. pylori
Inadequate treatment

31. GASTRINOMAS (zollinger-Ellison syndrome)
is caused by ectopic secretion of gastrin by a PET (i.e., gastrinoma), which causes excessive gastric acid secretion, characteristically causing peptic disease (often severe) and/or gastroesophageal reflux disease (GERD).
It is characterized by Prominent gastric folds on UGI endoscopy or X-ray (90%), Multiple peptic ulcers or ulcers in unusual locations (1%-5%), Complicated PUD (gastric outlet obstruction, 10%; perforation, 7%; recurrent bleeding, 5%-10%) and Esophageal stricture caused by PUD (3%-4%).
The diagnosis of ZES requires the demonstration of acid hypersecretion in the presence of hypergastrinemia (assessments of fasting serum gastrin levels that will be increased), if the fasting serum gastrin level is normal, especially in repeated determinations, the diagnosis of ZES is very unlikely.