Peptic ulcer definition

❑ Is a sore on the lining of stomach or

small intestine (duodenum)
➢ peptic ulcer in stomach called
gastric ulcer
➢ peptic ulcer in duodenum called
duodenal ulcer

Gastric ulcer Duodenal ulcer

Diffused epigastric pain Point tenderness epigastric
Pain exacerbated with eating pain
Pain relieved by eating
Etiology and risk factors
1-H.pylori
2-stress
3-NSAIDs
4-zollinger Ellison syndrome
5-food:caffeine &smoking & alcohol

Signs and symptoms

1. epigastric pain
2. Heartburn
3. Nausea& vomiting
4. bloating
5. occasionally anorexia weight loss
6. melena (Black stool)
❑ Management of PUD
Treatment goals
1-Relieving ulcer pain 2-Healing the ulcer
3-Preventing ulcer recurrence 4-Reducingulcercomplications(Bleeding & perforation)

❖ Non pharmacological management

• Avoid stress
• Smoking& alcohol& caffeine
• Spicy food
• Avoid the long term use of Non selective NSAIDs
❖ Pharmacological management
1-Antacid (symptomatic relief )
2-Anti-secretory drugs
3-Cyto protective drugs
4-Treatment of HP induced peptic ulcer
❑ Antacid (symptomatic relief)
❑ MOA : Neutralize gastric HCL

Sodium bicarbonate Calcium carbonate Mg & Al hydroxide

• provide rapid pain relief • 50%act locally&50% Maybe • Act locally non-absorbable
• Could be absorbed absorbed (Mg Oxide &Hydroxide)cause diarrhea
systemically and cause • it may cause calcium (Al hydroxide)cause constipation
sodium& water retention stones& milk alkali • Why use Mg hydroxide and Al
and systemic alkalosis syndrome hydroxide antacids in combination?
• contraindicated in • Ca may Stimulate Gastrin • Mg cause diarrhea and Al cause
hypertensive patient Hormone so increase constipation so to neutralize their
gastric HCL (rebound effect and not occur change in
hyperacidity) bowel habit
Uses
• Give symptomatic relief for patient with heart burn& acid reflux &peptic ulcer but not used at
all as a treatment to treat peptic ulcer
Side effect
• Antacids cause chemical complex (chelation) so must leave a gap of time(1hr) between
antacids and other drugs
❑ Anti-secretory drugs
❖ Anti muscarinic drugs (pirenzepine) 7% effective
MOA: block muscarinic receptor and prevent action of Ach on muscarinic receptor so inhabit
gastric secretion
This category is not common in treatment of peptic ulcer

❖ H2-bockers(Cimitidine& Rantidine &Famotidine) 70% effective

MOA:H2-blockers work by decreasing the amount of acid produced by the stomach
Uses
1- Peptic ulcer 2- Stress ulcer
3- Chronic use of NSAIDs(Rheumatoid arthritis) 4- Zollinger Ellison syndrome
Side effects
• Cimetidine is potent inhibitor of the cytochrome P450 which can result in significant drug interactions so
not given with narrow therapeutic index drugs
• Cimetidine may also cause low sperm count &impotence by inhibition the binding of testosterone to
androgen receptors(anti-androgenic side effect) but These side effects are reversible.
• Rantidine has carcinogenic effect so withdrawn from the market.
• Not stopped suddenly as may cause rebound ulceration.
❖Proton pump inhibitors PPIs up to 95% effective
• Omeprazole,pantoprazole,lansoprazole
• Proton pump inhibitors (PPIs) are medicines that work by reducing the amount of gastric HCL made by
irreversibly inhibiting the stomach's H+/K+ ATPase proton pump.
• Proton-pump inhibitors have largely superior effect than H2-receptor antagonists.
• Drug of choice in treatment of Peptic ulcer. Very potent drugs
• The rate of absorption is decreased by concomitant food intake. It should be taken 30 minutes before meal.
• The PPIs are prodrugs. These prodrugs require gastric acid secretion to be converted to the active form.
• The duration of action ranges from 15 to 28 hours so, it has been taken once or twice daily
• Omeprazole reduce absorption of Clopidogrel by blocking the conversion of it to its active form as
omeprazole inhibit CYP450 enzymes.
Side effect
Diarrhea ,skin rash, Vitamin B12 deficiency
Change bioavailability of some drugs
❖Cytoprotective agents
• Enhance defense force
• Cytoprotective agents stimulate mucus production and enhance blood flow to the lining of the
gastrointestinal tract.
Sucralfate Misoprostol
• It precipitates to damaged ulcer • Prostaglandin analogue
tissue form complexes, this MOA:
complex act as barrier that protects • Enhance mucus production
against acid and enzymes so healing • Vasodilatation so increase blood
can occur flow to gastric mucosa
• Sucralfate to be activated need Side effect
gastric HCL • Diarrhea
• Prevent irritation by HCL • contraindicated in pregnant woman
• prevent back diffusion as cause uterine contraction and
• prevent stimulation of chief cell may lead to abortion
that release pepsin
• stimulate prostaglandin synthesis
side effect
• Constipation
• contradicted in renal failure patient
 Colloid bismuth
• In presence of HCL colloid bismuth precipitate on ulcer base

Side effect
• Black teeth and black stool
• Bismuth may cause CNS problem as encephalopathy
Treatment of H.Pylori induced peptic ulcer
triple therapy (three based regimen)
➢ Proton pump inhibitor PPI
➢ Clarithromycin
➢ Metronidazole
Four based regimen P-Cat
➢ Proton pump inhibitor PPI
➢ Clarithromycin
➢ Amoxicillin
➢ Tinidazole
Cases
A female patient 57 years old has three months history of difficult moving due to left knee pain. Pain is
worsening with activity and relieving with rest. She used acetaminophen 500 mg with minimal relief. The
doctor had seen her in the clinic two months ago; the doctor performed the following investigations: CBC,
renal and liver functions which were normal. X-ray was performed on the left knee that showed osteoarthritis
case. The doctor recommended her to use acetaminophen 1 gm two times daily. Today, she tells the doctor
that there is minimal improvement in both pain and mobility. She is not smoker or alcohol consumer. There is
no history of ulcers or acid reflux. The doctor decides to initiate therapy with NSAIDS naproxen.
- Does this woman require gastro protection?
- Two years later, the woman has been admitted to the hospital with gastrointestinal bleeding. She had been
using naproxen 500 mg twice daily over the past two years to control the symptoms of arthritis. Endoscopy was
performed and revealed presence of duodenal ulcer. the bleeding was stopped and the woman starts PPI
therapy with pantoprazole IV (80 mg IV bolus followed by 8 mg per hour infusion for the next 72 hours). Now
there is no recurrent bleeding and the woman starts to eat. Infusion was stopped and a blood test for H. pylori
was negative. What would you recommend to continue the therapy of ulcer?
- Eight months after discharge from hospital, the woman has no signs of recurrent bleeding and continues using
of omeprazole 20 mg per day. She stopped using naproxen 500 mg twice daily and replaced it with
acetaminophen 1 gram four times a day to manage the left knee pain but the pain is worsening. Can the
woman take NSAIDS again to control the osteoarthritis?