Algorithm For Treatment of Peptic Ulcer Disease

Algorithm For Treatment of Peptic Ulcer Disease - The clinical presentation of PUD varies depending on the severity of epigastric pain and the presence of complications (presentation of peptic ulcer disease). Ulcer-related pain in duodenal ulcer often occurs 1 to 3 hours after meals and is usually relieved by food, but this is variable. In gastric ulcer, food may precipitate or accentuate ulcer pain. Antacids usually provide immediate pain relief in most ulcer patients. Pain usually diminishes or disappears during treatment; however, recurrence of epigastric pain after healing often suggests an unhealed or recurrent ulcer.

Epigastric pain does not define an ulcer. The absence of pain does not preclude the diagnosis especially in the elderly who may present with “silent” ulcer complications. The reasons for this are unclear, but may relate to differences in the way the elderly perceive pain or the analgesic effect of NSAIDs. Dyspepsia in itself is of little clinical value when assessing subsets of patients who are most likely to have an ulcer. Patients taking NSAIDs often report dyspepsia, but dyspeptic symptoms do not directly correlate with an ulcer. 

Patients with dyspeptic symptoms may have either uninvestigated (no upper endoscopy) or investigated (underwent upper endoscopy) dyspepsia. If an ulcer is not confirmed in a patient with ulcer-like symptoms at the time of endoscopy, the disorder is referred to as nonulcer dyspepsia. Ulcer-like symptoms may occur in the absence of peptic ulceration in association with H. pylori gastritis or duodenitis. There is no one sign or symptom that differentiates between H. pylori-associated and NSAID-induced ulcer.

Presentation of Peptic Ulcer Disease

General
• Mild epigastric pain or acute life-threatening upper gastrointestinal complications Symptoms
• Abdominal pain that is often epigastric and described as burning, but may present as vague discomfort, abdominal fullness, or cramping
• A typical nocturnal pain that awakens the patient from sleep (especially between 12 AM and 3 AM)
• The severity of ulcer pain varies from patient to patient, and may be seasonal, occurring more frequently in the spring or fall; episodes of discomfort usually occur in clusters, lasting up to a few weeks and followed by a pain-free period or remission lasting from weeks to years
• Changes in the character of the pain may suggest the presence of complications
• Heartburn, belching, and bloating often accompany the pain
• Nausea, vomiting, and anorexia, are more common in patients with gastric ulcer than with duodenal ulcer, but may also be signs of an ulcer-related complication

Signs
• Weight loss associated with nausea, vomiting, and anorexia
• Complications, including ulcer bleeding, perforation, penetration, or obstruction Laboratory tests
• Gastric acid secretory studies
• Fasting serum gastrin concentrations are only recommended for patients who are unresponsive to therapy, or for those in whom hypersecretory diseases are suspected
• The hematocrit and hemoglobin are low with bleeding, and stool hemoccult tests are positive
• Tests for Helicobacter pylori 

Other diagnostic tests
• Fiberoptic upper endoscopy (esophagogastroduodenoscopy) detects more than 90% of peptic ulcers and permits direct inspection, biopsy, visualization of superficial erosions, and sites of active bleeding
• Routine single-barium contrast techniques detect 30% of peptic ulcers; optimal double-contrast radiography detects 60% to 80% of ulcers

General Approach to Treatment

The treatment of PUD centers on healing the ulcer and reducing the risk of ulcer recurrence and related complications. Drug regimens containing antimicrobials such as clarithromycin, metronidazole, amoxicillin, and bismuth salts and antisecretory drugs (PPIs or H2RAs) relieve ulcer symptoms, heal the ulcer, and eradicate H. pylori infection. Successful eradication will alter the natural history of PUD and cure the disease. PPIs are preferred to H2RAs or sucralfate for healing H. pylori-negative NSAID ulcers because they accelerate ulcer healing and provide more effective relief of symptoms. Treatment with a PPI should be extended to 8 to 12 weeks if the NSAID must be continued. A PPI-based H. pylori eradication regimen is recommended in H. pylori-positive patients with an active ulcer who are also taking an NSAID. 

Prophylactic cotherapy with either a PPI or miso-prostol decreases ulcer risk and upper GI complications in patients taking nonselective NSAIDs. A COX-2 inhibitor may be used as an alternative to a nonselective NSAID, but the risk of adverse cardiovascular effects must be weighted against the gastroprotective benefits in each patient. The optimal therapeutic strategy for patients at very high risk of NSAID-related GI events is not known, but selected patients may benefit from the use of a COX-2 inhibitor and a PPI.

Dietary modifications are important for patients who are unable to tolerate certain foods and beverages. Lifestyle modifications such as reducing stress and decreasing or stopping cigarette smoking is encouraged. Some patients may require radiographic or endoscopic procedures for a definitive diagnosis or for complications such as bleeding. Surgery may be necessary in patients with ulcer-related complications.

Nonpharmacologic Therapy

Patients with PUD should eliminate or reduce psychological stress, cigarette smoking, and the use of nonselective NSAIDs (including aspirin). Although there is no “antiulcer diet,” the patient should avoid foods and beverages (e.g., spicy foods, caffeine, and alcohol) that cause dyspepsia or that exacerbate ulcer symptoms. If possible, alternative agents such as acetaminophen, nonacetylated salicylate (e.g., salsalate), or COX-2 inhibitors should be used for relief of pain. Elective surgery for PUD is rarely performed today because of highly effective medical management such as the eradication of H. pylori and the use of potent acid inhibitors. A subset of patients, however, may require emergency surgery for bleeding, perforation, or obstruction. In the past, surgical procedures were performed for medical treatment failures and included vagotomy with pyloroplasty or vagotomy with antrectomy.

Vagotomy (truncal, selective, or parietal cell) inhibits vagal stimulation of gastric acid. A truncal or selective vagotomy frequently results in postoperative gastric dysfunction and requires a pyloroplasty or antrectomy to facilitate gastric drainage. When an antrectomy is performed, the remaining stomach is anastomosed with the duodenum (Billroth I) or with the jejunum (Billroth II). A vagotomy is unnecessary when an antrectomy is performed for gastric ulcer. The postoperative consequences associated with these procedures include postvagotomy diarrhea, dumping syndrome, anemia, and recurrent ulceration.

Salam

by Umaee

Algorithm For Treatment of Peptic Ulcer Disease

Source: Pharmacotherapy 7th

Share on :

Tweet

Recommended Posts :