Peptic ulcer disease (PUD) of the stomach and duodenum
Peptic ulcers are raw patches that are usually 1-2cm
in diameter. The surface mucosa (protective skin) has been removed. An ulcer
in the stomach is called a gastric or stomach ulcer. In the duodenum it's
called a duodenal ulcer.
There are several factors that increase a person's risk of getting a
- infection with bacteria called Helicobacter pylori (H. pylori) - this
is almost always present in people with ulcers, although it's also found
in the stomachs of many people without ulcers or indigestion symptoms
- regularly taking certain medicines, particularly aspirin and other
non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, naproxen
- blood group O
- drinking alcohol in excess
Gastric ulcer typically causes a sharp pain in the stomach soon after
eating, whereas the pain of a duodenal ulcer is typically relieved by eating,
or by drinking milk. Other symptoms may include:
- General discomfort in the stomach
- Loss of appetite or, rarely, increased appetite
- Loss of weight
Bleeding peptic ulcer
Diagnosis is established either by endoscopy
or indirectly by UGI series. In this case if gastric
ulcer is seen a biopsy is mandatory.
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Patients under 50 years that do not exhibit
gastrointestinal bleeding, anorexia, early satiety
or weight loss with the 1st episode of dyspepsia can be given emperic antiulcer
therapy 4-6 weeks. Failure to respond by 2 weeks or recurrence warrants
Document H.pylori infection and
document other aetiological factors that would lead to
1. Active ulcer not attributable to H.pylori:
H2 receptor antagonists: PO bid for 8
famotidine 20 mg
nizatidine 150 mg
* parenteral therapy is reserved for those
* all H2 antagonists at the above doses are equal in efficacy
Proton pump inhibitors: PO bid 4wks
in duodenal and 8 wks in gastric
Lanzoprazole 30 mg
g qid for acute therapy
Should not be administered with H2 antagonist or antacid as it requires
an acid pH to become activated.
Antacids: because of their frequent dosing and side effects they
are best used as supplemental therapy for pain relief. However, due to their
low cost they are sometimes prescribed for patients with low funds.
2. Patients with active peptic ulcer associated with
Antisecretory therapy as above +
erradication therapy for 1st 2 weeks. Irradication requires
triple antibiotic therapy.
Prevention of relapse
Recurrence rate is as high as
75% in the 1st year.
Maintenance therapy by ? dose
H2 antagonists before bedtime for 6 months.
Alternatively if patient was on
sucralfate he is maintained with 1g bid.
Erradicating H. pylori decreases
the recurrence rate to as low as 10%.
Evaluation of response and follow up
80% DU heal on the
above regimen. if not successful
then note patient compliance, the use of risk factors. One must document
unhealed ulcer by endoscopy. If these patients
were on H2 antagonists then switch to proton pump
blockers. Consider the possibility of
Zollinger ? Ellison syndrome.
Therapy takes longer and should
be continued for 8 weeks then evaluation with endoscopy is done and biopsy
is taken. If these are negative then treatment is continued for longer.
If this fails then either the dose is increased or switched to proton pump
blockers. Otherwise consider surgery.