3.a. peptic ulcer (dr.fauzi yusuf, sp.pd, kgeh)
TRANSCRIPT
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PEPTIC ULCER
Fauzi YusufGastroenterohepatologi Division
Internal Medicine DepartmentSyiah Kuala University/Zainoel Abidin Hospital
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PEPTIC ULCER
Incidens in Western Contries:Female 4 15 % & Male 10 15 %Patient Problem:Suffer recurrency / relaps, loss in theworks, cost of medication expensiveUpper GI endoscopy in Cipto Mangunkusumo
Hospital:The incidene of Peptic Ulcer: 6,93 7,10%;Duodenal Ulcer: Gastric Ulcer = 2:1
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Common Causes of Death in U.S.
0
1
2
3
4
5
6
7
8
9
Leukemia AIDS NSAID-GI
disease
Melanoma Asthma Cervical
cancer
D e a
t h p e r 1
0 0
, 0 0 0
Wolfe et al. NEJM 1999
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Type of Prevalence of upper gastrointestinal disease (UGI) indyspepsia cases, Internal Medicine Dept. Faculty of Medicine /Cipto Mangunkusumo Hospital and Zainoel Abidin Hospital Banda
AcehType of Disease RSCM
(1994)RSUZA
(2001/2002)
Normal
Gastritis/erosive GastritisDuodenitisEsophagitisBile Reflux Gastritis
Duodenal UlcerGastric UlcerPortal Hypertensive gastropathyGastric Tumor
Others
28
44,677,675,834,5
3,52,21,21
3,16
17,5
40,57,05
10,701,05
2,0371,053,050,95
0,024
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DEFINITION
Peptic Ulcer: Damage of mucosallayer/muscularis mucosa or deeper untilsubmucosa of the stomach/duodenum, ulceredge surounded by acute and chronicinflamatory cells; the diameter 5 mm Erosion: damage < 5 mm and the depth not
over than muscularis mucosa
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Differences between NSAID and H.pyloriinduced ulcers
NSAIDs induced H.pylori
Patients demographics Elderly more than youngWomen more oftenthan men
Young more often thanelderlyMen more often thanwoman
Site of damage Gastric more thanduodenal
Duodenal more thangastric
Symptoms More often
asymptomatic
Usually pain and or
dyspepsiaHistology Surrounding mucosa
normal(foveolar hyperplasia)
Surrounding mucosainflammed(active chronicgastritis)
Scarpignato,1997
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Risk Factors for NSAIDs InducedGastroduodenal Ulceration
Established Possible
Advanced age Concomitant infection withHistory of ulcer H. pyloriConcomitant use of glucocorticoids Cigarette smokingHigh-dose NSAIDs Alcohol consumptionMultiple NSAIDsConcomitant use of anticoagulantsSerious or multisystem disease
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Bicarbonate
PROTECTIVEFACTORS
Prostaglandins
Mucosal bloodsupply
Surfaceepithelial
cells
Mucus layer
AGGRESSIVE FACTORS
Acid + pepsin H. pylor i
Seager & Hawkey, BMJ 2001; 323 : 1236 9.
Pathogenesis of NSAID-induced ulcers
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Peptic Ulcer Clinical Manifestation
1. History of illnessNoneDyspeptic Symptom:
Epigastric Pain, Nausea, Vomiting,anorexia,epigastric discomfort, etcEpigastric PainEpisodic, Nocturnal, Pain -Food- Relief pattern
can be pointed atLoss of body weightHematemesis and Melena
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Peptic Ulcer Clinical Manifestation (Cont)
2. Physical Examination: Epigastric Pain,bloating, succusion splash (obstruction),anemia (bleeding), Perforation symptom
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Diagnosis ofHelicobacter Pylori Infection
NON-INVASIVEUrea Breath TestSerum serology for Hpantibody testWhole blood serology forHp antibody testSaliva Assay for Hpantibody test
Helicobacter Pylori stoolantigent (HpSA) test
INVASIVE(biopsy & endoscopy)
Culture test
Histopatology testUrease testPCR
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MANAGEMENT
General/supportifStop/Inhibit aggressive factorIncrease the defensive factorOther treatmentThreat the complication
Avoid ulcer relaps/recurrence
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Indication of Upper Gastrointestinal/Esophago-gastro-duodenoscopy
Age over 45 years old Alarm signsTherapy failureHistory of Peptic ulcer + ComplicationPatient enqueryThe use of aspirin or NSAID
Abnormality in Upper GI X-Ray (OMD)
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H Pylori Eradication (KSHPI)
Tripple therapy (1 or 2 weeks):PPI + Amoxicillin + ClarithromycinPPI + Metronidazole + ClarithromycinPPI + Metronidazole + Tetracyclin (Alergy to clarithromycin)
Quadrupple therapy ( 1 or 2 weeks):If fail to therapy combination 3 drugs:
Bismuth + PPI + Amoxicillin + ClarithromycinBismuth + PPI + Metroniudazole + Clarithromycin
High resistency area :PPI + Bismuth + Tetracyclin + Metronidazole
PPI 2 x/d: Omeprazole/Esomeprazole 20 mg, Lansoprazole 30mg, Pantoprazole 40 mg, Rabeprazole 10 mg Amoxicillin 2 x 1000 mg/d, Clarithromycin 2 x 500 mg/d,metronidazole 3 x 500 mg/d, tetracyclin 4 x 250 mg/d, Bismuth 4x 120 mg/d
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CONCLUSIONS
The three aims of ulcer treatment are :Symptom relief, Healing of the ulcer,prevention of recurrence.
For H Pylori Positive, Eradication therapyshould be given to prevent ulcer recurrenceFor optimal ulcer healing, NSAIDS should be
stop is possible.
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