Peptic Ulcers and Treatment Overview

Peptic Ulcers

• Peptic ulcers are breaks in the stomach or duodenum lining, penetrating the mucosa and potentially the submucosa.
• Duodenal ulcers are often linked to excess stomach acid, while gastric ulcers are more associated with decreased protective factors.
• Common causes include alcohol consumption, NSAID use, stress, and most significantly, Helicobacter pylori.

Helicobacter pylori

• H. pylori is responsible for the majority of peptic ulcers.
• Diagnosed by a urea breath test, where a patient ingests radioactive urea.
• H. pylori possesses urease, breaking urea into ammonia and bicarbonate. Some bicarbonate is exhaled as CO2, allowing quantifiable measurement via the detected radioactive CO2.

Symptoms

• Pain is a primary symptom.
• Duodenal ulcers cause pain upon fasting, relieved by eating.
• Gastric ulcers cause pain worsening with eating.
• Bleeding can also occur.

Treatment: Medications

Proton Pump Inhibitors (PPIs)

• Inhibit acid production by blocking the H+/K+ ATPase (proton pump).
• Examples: Omeprazole, Esomeprazole, Pantoprazole, Lansoprazole
• Indications: GERD, peptic ulcer, Zollinger-Ellison syndrome, acid reflux.
• Mechanism: Irreversibly bind to H+/K+ ATPase; lipophilic at neutral pH, becoming protonated and trapped inside parietal cells when in the acidic environment of the parietal cell.
• Dosage: Oral enteric-coated granules to prevent stomach acid destruction.
• Side effects: Gastrointestinal issues, increased C. difficile infection risk, decreased iron & B12 absorption, long-term: decreased calcium absorption, osteoporosis.

Histamine 2 Receptor Antagonists (H2RAs)

• Block histamine 2 receptors, which stimulate acid secretion.
• Examples: Cimetidine, Ranitidine, Famotidine
• Indications: GERD, peptic ulcer, stress ulcer prophylaxis
• Mechanism: Decrease acid and pepsin secretion, promote ulcer healing.
• Pharmacokinetics: Primarily eliminated through the kidneys
• Side effects: Cimetidine: erectile dysfunction, gynecomastia; general: few

Muscarinic Antagonists

• Block neuronal regulation of acid production.
• Examples: Pirenzepine, telenzepine
• Indications: Ulcers unresponsive to PPIs or H2RAs
• Side effects: Parasympatholytic effects (bronchodilation, decreased secretions)

Antacids

• Neutralize stomach acid through base interactions
• Types: Systemic (absorbed, causing metabolic alkalosis) and non-systemic (not absorbed).
• Examples: Sodium bicarbonate, Magnesium hydroxide, Aluminum hydroxide
• Indications: Symptomatic relief for GERD, heartburn (non-systemic favoured).
• Mechanism: Salts of bases neutralize stomach acid
• Side effects: Potential for metabolic alkalosis(systemic), discomfort, and flatulence (due to CO2 formation). Interactions possible with other drugs.
• Counterindications: Renal failure patients (hyperaluminaemia, hypermagnesaemia) should avoid. Milk-alkali syndrome risks with excessive use

Mucosal Protectants

• Enhance endogenous mechanisms or provide a physical barrier.

• Sucralfate: Forms a protective layer on the mucosa, needs acidic pH to work. Primarily for prophylaxis.

• Bismuth compounds: Bactericide against H. pylori, protective layer, rarely used due to potential discoloration and encephalopathy

• Misoprostol: Prostaglandin E1 analogue, increases mucosal protection, Decreases secretion but increases mucous secretion, blood flow. Primarily for use in long-term NSAID users to prevent NSAID related ulcers. Common side effects: Diarrhea and nausea.

• Carbenoxolon: Increases gastric mucus, decreases acid secretion. Not frequently used due to potential mineralocorticoid-like side effects.

Antibacterial Treatment

• Triple therapy (for H. pylori): 7 days of a PPI, clarithromycin, and either amoxicillin or metronidazole
• Quadruple therapy (for H. pylori): Triple therapy plus bismuth

Explore the causes, symptoms, and treatment options for peptic ulcers in this comprehensive quiz. Learn about the role of Helicobacter pylori and the effectiveness of Proton Pump Inhibitors in managing these conditions. Test your knowledge and deepen your understanding of ulcer pathophysiology.