Medical Management of H pylori Infection

Peptic Ulcer Disease (PUD)

• A peptic ulcer is an excavation (hollowed-out area) that forms in the mucosal wall due to erosion of the GI mucosa, resulting from the digestive action of HCl acid and pepsin.

Types of PUD

• Acute PUD: characterized by superficial erosion, minimal inflammation, and short duration; resolves quickly when the cause is identified and removed.
• Chronic PUD: characterized by muscular wall erosion with formation of fibrous tissue, long duration, and present continuously for many months or intermittently; 4 times as common as acute erosion.

Pathophysiology

• Causes of erosion: increased concentration or activity of HCl-pepsin or decreased resistance of gastric mucosa.
• Patients with duodenal ulcer secrete more acid, while those with gastric ulcer secrete normal or decreased levels of acid.

Etiology and Pathophysiology

• Stomach protective mechanisms: gastric mucosal barrier, mucus secretion, and bicarbonate secretion.
• Impaired mucosal barrier leads to cellular destruction and inflammation.
• Risk/predisposing factors: smoking, alcohol, stress, eating habits, familial tendency, people with blood type O, milk and caffeinated beverages, chronic use of NSAIDs, aspirin, corticosteroids, cytotoxic drugs, and Helicobacter pylori infection.

Gastric Ulcers

• Occur in any portion of the stomach, with normal or hyposecretion of gastric acid (HCl).
• Weight loss may occur, and pain occurs 1/2 to 1 hour after a meal, which may be relieved by vomiting; ingestion of food does not help and may increase pain.
• Vomiting is common, and hemorrhage is more likely to occur than with duodenal ulcer.

Duodenal Ulcers

• Account for ~80% of all peptic ulcers, with a familial tendency (people with blood group O have an increased risk).
• Associated with increased HCl acid secretion, and H. pylori is found in 90% to 95% of patients, but not all individuals with H. pylori develop ulcers.
• Vomiting is uncommon, and hemorrhage is less likely than with gastric ulcer, but if present, melena is more common than hematemesis; more likely to perforate than gastric ulcers.

Clinical Manifestations

• Symptoms may last for a few days, weeks, or months and may disappear then reappear.
• Many people with ulcers have no symptoms; perforation or hemorrhage may occur in 20%-30% of patients who had no preceding manifestations.
• Dull, gnawing pain or burning sensation in the midepigastrium or back, which is relieved by eating or taking antacids.

Medical Management

• Conservative therapy consists of adequate rest, dietary modification, drug therapy, elimination of smoking and alcohol, and stress management.
• Pharmacologic therapy includes triple therapy (2 antibiotics and a proton pump inhibitor) or quadruple therapy (2 antibiotics, proton pump inhibitor, and bismuth salts) for 10 to 14 days to treat H. pylori infection.

Surgical Therapy

• Surgical procedures: vagotomy (totally or partially) with or without pyloroplasty, performed to reduce gastric acid secretion, and done in conjunction with gastrectomy; pyloroplasty: increases gastric emptying.

Nursing Care Plan

• Assessment: pain and methods used to relieve it, vomiting, food habits, lifestyle habits, use of irritating substances, smoking, alcohol, NSAIDs, anxiety, stress, family history of ulcer disease.

This quiz covers the conservative therapy and pharmacologic therapy for the management of H pylori infection, including dietary modification, drug therapy, and stress management.