2. CASTRIC ULCER CASE A 72-year-old male was seen by his physician because of epigastric distress shortly after eating a meal, and occasionally during the meal itself. He had lost some 10 lb during the past 2 weeks. He was told that he probably had ulcer disease and was given histamine receptor antagonists.

3. On follow-up 6 weeks later, he reported feeling better, although not entirely normal. He had not regained any weight. Endoscopy was advised. In the fundus of the stomach, a 3-cm gastric ulcer was noted on the ventral Wall. The biopsies showed only chronic inflammatory changes.

4. Another 6-week course of medical therapy was instituted and sulcrulfate, a mucosal barrier agent, was added. On return visit the ulcer was only partially healed, and operation was advised. On follow-up 1 year later, he was asymptomatic and not taking any medications. His weight had Returned to normal.

5. A peptic ulcer is a sore in the lining of your stomach or your duodenum, the first part of your small intestine. A burning stomach pain is the most common symptom. The pain : Starts between meals or during the night Briefly stops if you eat or take antacids Lasts for minutes to hours Comes and goes for several days or weeks

6. Peptic ulcers happen when the acids that help you digest food damage the walls of the stomach or duodenum. The most common cause is infection with a bacterium called Helicobacter pylori Another cause is the long-term use of nonsteroidal anti-inflammatory medicines (NSAIDs) such as aspirin and ibuprofen. Stress and spicy foods do not cause ulcers, but can make them worse.

7. Peptic ulcers will get worse if not treated. Treatment may include medicines to reduce stomach acids or antibiotics to kill H. pylori. Antacids and milk can't heal peptic ulcers. Not smoking and avoiding alcohol can help. You may need surgery if your ulcers don't heal.

8. Treatment for peptic ulcers typically involves antibiotics to kill the H. pylori bacterium and other medications to reduce the level of acid in your digestive system to relieve pain and encourage healing. You may take antibiotics for two weeks and acid- reducing medications for about two months.

9. If your peptic ulcer isn't caused by H. pylori, you won't need antibiotics. Instead, your doctor may recommend treatments for your specific situation. For instance, if pain relievers caused your ulcer, your doctor may recommend a different pain reliever or a different dose. Your doctor may also recommend acid-reducing medications to allow your ulcer to heal. You may take these medications for two months or more.

10. How is an H. pylori-induced ulcer treated? Peptic ulcers caused by H. pylori are treated with drugs that kill the bacteria, reduce stomach acid, and protect the stomach and duodenal lining. Antibiotics are used to kill H. pylori. Antibiotic regimens may differ throughout the world because some strains of H. pylori have become resistant to certain antibiotics—meaning that an antibiotic that once destroyed the bacterium is no longer effective. Doctors closely follow research on antibiotic treatments for H. pylori infection to know which treatment strategy will destroy which strain.

11. Medicines that reduce stomach acid include proton pump inhibitors (PPIs) and histamine receptor blockers (H2 blockers). Both acid-reducing medicines help relieve peptic ulcer pain after a few weeks and promote ulcer healing. PPIs and H2 blockers work in different ways: PPIs suppress acid production by halting the mechanism that pumps acid into the stomach. H2 blockers work by blocking histamine, which stimulates acid secretion.

12. While PPIs cannot kill H. pylori, research shows they do help fight the H. pylori infection. Research also shows that after 4 weeks of treatment, patients taking PPIs had earlier pain relief and better healing rates than those taking H2 blockers. Bismuth subsalicylate (Pepto-Bismol) coats ulcers, protecting them from stomach acid. Although bismuth subsalicylate may kill H. pylori, it is used with—not in place of—antibiotics in some treatment regimens.

13. In the United States, clarithromycin-based triple therapy— triple therapy, for short—is the standard treatment for an ulcer caused by H. pylori. The doctor prescribes the antibiotic clarithromycin, a PPI, and the antibiotics amoxicillin or metronidazole for 10 to 14 days. Because research shows higher cure rates with 14 days of treatment, some doctors now prescribe triple therapy for this longer period. Bismuth quadruple therapy is another treatment strategy used in the United States. The patient takes a PPI, bismuth subsalicylate, and the antibiotics tetracycline and metronidazole for 10 to 14 days.

14. Bismuth quadruple therapy is used to treat patients in one of several situations, including if the patient cannot take amoxicillin—a penicillin-like antibiotic— because of a penicillin allergy has been treated before with a macrolide antibiotic, such as clarithromycin is still infected with H. pylori because triple therapy failed to kill the bacteria

15. Triple therapy and bismuth quadruple therapy may cause nausea and other side effects, including stomach upset diarrhea headache a metallic taste a darkened tongue or stools flushing when drinking alcohol sensitivity to the sun

16. Patients should discuss any bothersome side effects with their doctor, who may prescribe other medicines to kill the bacteria and cure the ulcer. Although antibiotics can cure 80 to 90 percent of ulcers caused by H. pylori, eliminating the bacteria can be difficult. Patients must take all medicines exactly as prescribed, even when the peptic ulcer pain is gone.

17. At least 4 weeks after treatment, doctors test patients using a breath or stool test to be sure the H. pylori infection has been cured. Blood tests are not useful after treatment because a patient's blood can test positive for H. pylori even after the bacteria have been eliminated. If infection is still present, ulcers could recur or, less commonly, stomach cancer could develop. Thus, some patients need to take more than one round of medicines to kill the H. pylori bacteria. Bismuth quadruple therapy is one of several treatments used after initial treatment has failed—a strategy called “rescue” or “salvage” therapy. In the second round of treatment, the doctor prescribes different antibiotics than those used in the first round. Amoxicillin, however, can be used again to treat H. pylori infection because H. pylori resistance to this antibiotic is rare.

18. NSAID-induced Ulcers without H. pylori Present If NSAIDs are the cause and H. pylori is not present, the doctor prescribes medicine to reduce stomach acid. Proton pump inhibitors (PPIs) and histamine receptor blockers (H2 blockers) are acid-reducing medicines that help relieve peptic ulcer pain after a few weeks and promote ulcer healing. Research shows that after 4 weeks of treatment, patients taking PPIs had earlier pain relief and better healing rates than those taking H2 blockers.

19. NSAID-induced Ulcers with H. pylori Present In addition to treating an NSAID-induced ulcer with a PPI or an H2 blocker, antibiotics are prescribed if an H. pylori infection is present. Antibiotics destroy the H. pylori bacteria and cure the infection. Bismuth subsalicylate (Pepto-Bismol) also may be prescribed to protect the stomach lining from acid. In the United States, clarithromycin-based triple therapy—triple therapy, for short—is the standard treatment for an H. pylori infection. The doctor prescribes the antibiotic clarithromycin, a PPI, and the antibiotics amoxicillin or metronidazole for 10 to 14 days. Because research shows higher cure rates with 14 days of treatment, some doctors now prescribe triple therapy for this longer period.

20. Bismuth quadruple therapy is another treatment strategy used in the United States. The patient takes a PPI, bismuth subsalicylate, and the antibiotics tetracycline and metronidazole for 10 to 14 days. Patients should discuss any bothersome side effects with their doctor, who may prescribe other medicines to kill the bacteria and cure the ulcer. Although antibiotics can cure 80 to 90 percent of H. pylori infections, 3 eliminating H. pylori can be difficult. Patients must take all medicines exactly as prescribed, even when the peptic ulcer pain is gone.

21. Thank You