Written by Dr.Md.Redwanul Huq (Masum)

Sunday, 15 January 2012 16:03

Definition:

A peptic ulcer is gastric acid induced erosion in the lining of the stomach or the first part of the small intestine (duodenum) leading to a local defect or excavation due to active  inflammation. Duodenal ulcers (DUs) and gastric ulcers (GUs) are included in Peptic Ulcer Diseases.

Aetiologic agents:

Most important causes are-

1. Helicobacter pylori infection
2. Non Steroidal Anti-Inflammatory Drugs(NSAIDs)
3. Smoking.

Other causes are-

1. Chemotherapy
2. Glucocorticoids (along with NSAIDs)
3. Clopidogrel
4. Bisphosphonates
5. Alcohol
6. Infection with Herpes simplex virus, Cytomegalovirus or Helicobacter heilmanni
7. Gut ischemia
8. Hypovolemia
9. Shock
10. Duodenal obstruction
11. Radiation therapy
12. Crohn’s disease
13. Zollinger Ellison Syndrome
14. Sarcoidosis.

Symptoms:

• Recurrent burning or aching abdominal pain which-

*occurs 1-3 hours after meal (in upper-right abdomen in DU) or immediately after taking meal(under the left part of the xiphoid process in GU)

*sometimes extends to the back

*usually goes away after taking an antacid or acid reducer or food (in case of duodenal ulcer).

•  Loss of appetite
• Nausea (more common in gastric ulcer,GU)
• Bloating
• Weight loss (more common in gastric ulcer,GU)

[ Symptoms may be absent in some cases of peptic ulcer diseases]

Serious symptoms (symptoms of complications):

•  Vomiting of blood (like coffee grounds) and passage of black tarry stool [in bleeding from upper GIT]
• Abdominal pain increased with meals, nausea and vomiting of undigested food materials after meals [in Gastric Outlet Obstruction, GOO]
• Sudden onset of severe and generalized abdominal pain followed by rigid, hard abdomen which is tender to touch [in perforation]
• Constant dyspepsia (not relieved by food or antacids), abdominal pain radiating to back [in penetrating ulcer involving pancreas]
• Development of fainting, excessive sweating, or confusion.

Signs:

There may be no sign. But most frequent sign is- Tenderness in the epigastrium.

Signs of Complications:

• Anaemia, dehydration, tachycardia – in Bleeding PUD
• Boardlike rigid, severely tender abdomen- in Perforation
• Succussion splash present- in GOO.

Investigations:

Following investigations can be done in Peptic ulcer diseases (PUD):

INVESTIGATIONS	POSSIBLE FINDINGS
	DU	GU
Endoscopy of upper GIT (with or without Biopsy and Histopathology)	Oval, round, linear or frost-like ulcers in Duodenum covered with white or gray colored mass ( Biopsy and Histopathology should be done in cases of malignant lesions )	Oval, round, linear or frost-like ulcers in Stomach covered with white or gray colored mass ( Biopsy and Histopathology should be done in cases of malignant lesions )
Barium meal X-ray	Well demarcated crater in Duodenum(mostly in the bulb)	Discrete crater in the stomach with radiating mucosal folds which are originating from the margin of the ulcer
Haemoglobin	Usually normal, decreased if there is bleeding from ulcer	Usually normal, decreased if there is bleeding from ulcer
ESR	Usually normal, high if the ulcer is malignant	Usually normal, high if the ulcer is malignant
Investigations for diagnosis of Helicobacter pylori
Non-invasive tests- a)Serological test-detection of Anti H.pylori antibody b) 13 C- or 14 C- Urea breath test- c) Monoclonal antibody stool antigen test
Invasive tests (from antral biopsy)- a) Rapid urease tests,e.g.CLO,pyloritek, Hpfast, Pronto Dry b)Histopathology c)Culture

Treatment of peptic ulcer:

Treatment of PUD by Helicobacter pylori infection:

a) A Strip containing-
1 Cap. Lansoprazole 30mg,
1 Tab. Clarithromycin 500mg,
2 Cap. Amoxycillin 500 mg;
-1 strip -bid- (½ HBM) ————— 7 – 14 D

Then, Cap.Omeprazole (20/40 mg) / Tab. Esomeprazole (20/40 mg) /
Cap. Lansoprazole 30mg / Tab. Rabeprazole 20 mg / Tab. Pantoprazole (20/40 mg)
1 cap/tab-bid (½ HBM) —————7 – 14 D
[Tab. Rabeprazole can be taken after meal]

Or,
b) 1. Cap. Amoxycillin 500 mg
2 cap-bid (12 hourly) (AM) —————7 – 14 D
2.Tab.Clarithromycin (500 mg)
1 tab-bid (12 hourly) (AM) —————7 – 14 D
3. Cap.Omeprazole (20/40 mg) / Tab. Esomeprazole (20/40 mg) /
Cap. Lansoprazole 30mg / Tab. Rabeprazole 20 mg / Tab. Pantoprazole (20/40 mg)
1 cap/tab-bid (½ HBM) —————7 – 14 D
[Tab. Rabeprazole can be taken after meal]

Or,

c) 1. Tab. Metronidazole 400 mg
1 tab-bid (12 hourly) (AM) —————7 – 14 D
2.Tab.Clarithromycin (500 mg)
1 tab-bid (12 hourly) (AM) —————7 – 14 D
3. Cap.Omeprazole (20/40 mg) / Tab. Esomeprazole (20/40 mg) /
Cap. Lansoprazole 30mg / Tab. Rabeprazole 20 mg / Tab. Pantoprazole (20/40 mg)
1 cap/tab-bid (½ HBM) —————7 – 14 D
[Tab. Rabeprazole can be taken after meal]

Or,

d) 1.Tab. Azithromycin 500 mg
1 tab-once daily (½ HBM) —————7 – 14 D
2.Tab.Levofloxacin (500 mg)
1 tab-once daily (± M) ——————-7 – 14 D
3. Cap.Omeprazole (20/40 mg) / Tab. Esomeprazole (20/40 mg) /
Cap. Lansoprazole 30mg / Tab. Rabeprazole 20 mg / Tab. Pantoprazole (20/40 mg)
1 cap/tab-bid (½ HBM) —————7 – 14 D
[Tab. Rabeprazole can be taken after meal]

Or,

e) 1.Cap. Amoxycillin 500 mg
2 cap-bid (12 hourly) (AM) —————7 – 14 D
2.Tab.Levofloxacin (500 mg)
1 tab-once daily (± M) ——————-7 – 14 D
3. Cap.Omeprazole (20/40 mg) / Tab. Esomeprazole (20/40 mg) /
Cap. Lansoprazole 30mg / Tab. Rabeprazole 20 mg / Tab. Pantoprazole (20/40 mg)
1 cap/tab-bid (½ HBM) —————7 – 14 D
[Tab. Rabeprazole can be taken after meal]

Or,

f) 1. Tab. Metronidazole 400 mg
1 tab-bid (12 hourly) (AM) —————7 D
2.Tab. Tetracycline 500 mg
1 tab-qid(6 hourly) ————————- 7 D
3.Tab. Bismuth 120 mg
1 tab-qid(6 hourly) ————————- 7 D
4. Cap.Omeprazole (20/40 mg) / Tab. Esomeprazole (20/40 mg) /
Cap. Lansoprazole 30mg / Tab. Rabeprazole 20 mg / Tab. Pantoprazole (20/40 mg)
1 cap/tab-bid (½ HBM) —————7 D
[Tab. Rabeprazole can be taken after meal]

Indications for H.pylori eradication:

1.PUD by Helicobacter pylori infection
2. H. pylori-positive dyspepsia
3. MALToma

Treatment of NSAID induced PUD:

1.Cap. Omeprazole (20/40 mg)/ Tab. Esomeprazole (20/40 mg) /
Cap. Lansoprazole 30mg / Tab. Rabeprazole 20 mg / Tab. Pantoprazole (20/40 mg)
1 cap/tab-bid (½ HBM) —————1 / 2 M
[Tab. Rabeprazole can be taken after meal]
2.Tab.Misoprostol (200 microgm)
-1 Tab  6/8 hourly—————————————–1 / 2 M
3.Tab.Sucralfate (500/1000 mg)
1tab-6 hrly or, 2 tab-12 hourly (½HBM) —————1 M
4.Combination of Aluminium Hydroxide, Magnesium Hydroxide
& Simethicone in Tablet(Chewable)[2+2+2]
or Suspension form[2 tsf – tid] (½ HBM or 2 HAM)————-2 /4W.

Short-term management of acid peptic disorders:

Following drugs are used for short- term management of acid peptic disorders –
1. Antacids- Aluminium Hydroxide, Magnesium Hydroxide
2. H₂ receptor blockers- Ranitidine, Cimetidine, Famotidine, Nizatidine
3. Proton pump inhibitors (PPIs) – Omeprazole, Pantoprazole, Esomeprazole,Lansoprazole, Rabeprazole
4. Misoprostol
5. Sucralfate.

Surgical treatment of peptic ulcer:

Surgical treatment in PUD is indicated in following conditions-
1. Perforation of stomach or duodenum
2. Bleeding from ulcer
3. Gastric Outlet Obstruction
4. Recurrent ulcer after gastric surgery.

Complications of peptic ulcer:

1. Perforation of stomach or duodenum
2. Bleeding from ulcer
3. Gastric Outlet Obstruction

Lifestyle modification:

•  Eat or drink nothing for at least 2 hours before going to bed.
• Do not smoke or chew tobacco or consume alcohol.
• Avoid alcohol intake.
• Try to avoid stress.
• Avoid over-the-counter pain relievers like aspirin and NSAIDs ( such as Diclofenac sodium, Ibuprofen, Ketorolac, Etoricoxib etc) and take another medicine to protect your stomach according to your doctor’s prescription.

Dietary modification:

•  Avoid those foods that cause or increase heartburn or peptic ulcer pain.
• Eat smaller & frequent meals (6 small meals instead of 3 big meals).
• Don’t take excessive spices, concentrated meat broths and extractives.
• Eat slowly and masticate properly.
• Use moderate amounts of easily digestible fats like fat of whole milk, egg yolk, cream and butter.
• Avoid caffeine beverages such as tea, coffee and cola.
• Avoid fibrous nature of cereals, vegetables and fruits.
• Take protein rich bland diets.
• Avoid those foods which are mechanically, thermally and chemically irritating to mucosa of stomach and intestine.

Diets for different Stages of Peptic Ulcers:

Stage I Diet is advised during the active phase of ulcers (Having severe pain).
Stage II Diet is advised when the patient is relieved from symptoms and on bed rest, but the ulcers are not completely healed yet.
Stage III Diet is advised to follow throughout the patient’s life as a prophylactic measure.

Table : Three stage Diets for Uncomplicated Bleeding Peptic Ulcer Adult Patients

Stage I (Diet I)
Milk ,whole – 2 litersMilk powder ,whole – 200 g ;Dextrose –  200 g;(Total volume 2 liters , Total protein 120 g)The milk powder is reconstituted with milk & dextrose added to the mixture.
Stage II (Diet II )
Vegetarian	Non – Vegetarian
Milk – 2 litersMilk powder – 200 gCheese – 100 gBread – 200 gCustard powder – 50 g Sugar -100 g Glucose -100 g	Milk – 1.5 litersMilk powder – 100 gMeat – 200 gBread – 200 gCustard powder – 50 g Sugar -100 g Glucose -100 g
Stage III (Diet III )
Vegetarian	Non – Vegetarian
Rice – 100 gBread – 200 gBiscuits -100 gMilk – 1.5 litersCheese – 100 g Dal -60 g Fruits -200 g Sugar -100 g Glucose -100 g Butter -50 g	Rice – 100 gBread – 200 gBiscuits -100 gMilk – 1 literMeat – 150 g Dal -30 g Fruits -200 g Sugar -100 g Glucose -100 g Butter -150

Sample diet plan (Stage II Diet):

(For an adult non-vegetarian person having normal body weight)

Menu Plan

(Prepared by Mrs. Sharmin Sultana , M.S. in Food & Nutrition )

Meal	Menu	Amount
Early Morning	Milk with sugar	1 cup
Breakfast	Bread	2 slices
	Egg	One
	Milk	1 cup
	Papaya	50 gms
Mid Morning	Blenderized Rice Pudding (Phirni)	1 bowl
Lunch	Khichri with washed pulses	Good helping
	Chicken	1 / 2 piece(s)
Mid Afternoon	Fruit cream	1 bowl
Evening Tea	Bread	1 slice
	Milk	1 cup
Dinner	Khichri with washed pulses	Good helping
	Spinach, tender peas, carrots, beans	1½ cup
Before bed time	Caramel custard	1 bow