Definition:
Chronic mucosal ulcer of the distal stomach and proximal duodenum caused by excessive gastric secretions mostly hydrochloric acid and enzymes.
Etiologic factors:
1. H. Pylori infection
2. NSAIDS e.g. Aspirin
3. Smoking
4. Alcohol
5. Ischemia, hypoxia, shock etc.
Pathophysiology:
Etiologic factors cause - Imbalance of gastroduodenal mucosal defense - increased gastric acidity and peptic activity - impaired defense - delayed gastric emptying - duodenal gastric reflux - decreased retrograde motility impairs neutralization by pancreatic alkaline secretions.
Clinical features:
1. Burning or aching pain in epigastrium
2. Nausea and vomiting
3. Bleeding
4. Belching
5. Iron deficiency anemia
Complications:
1. Bleeding (most common)
2. Iron deficiency anemia
3. Pyloric obstruction
4. Perforation
Diagnosis:
1. Endoscopy:
- Most sensitive and specific
- Direct visualization of mucosa
2. Biopsy to rule out malignancy of H. Pylori infection
3. Tests for detection of H. Pylori
A) Invasive
- Rapid urease test
- Histology
- Culture
B) Non-invasive
Treatment:
Acid suppressing drugs:
1. Proton pump inhibitors: e.g. Pantoprazole, Omeprazole etc.
2. H2 receptor antagonists e.g. Ranitidine
3. Mucosal protective agents e.g. Sucralfate
4. Prostaglandin analogue e.g. Misoprostol
Regimen for H. Pylori eradication:
Triple therapy: Clarithromycin + Amoxicillin + Pantoprazole
Second line regimen:
1. PPI + Amoxicillin + Rifampicin - 10 days
2. PPI + Amoxicillin + Levofloxacin
3. PPI + Amoxicillin + Furazolidone
Sequential therapy:
PPI + Amoxicillin - 1st 5 days
PPI + Tinidazole + Clarithromycin - next
Note:
1. Duodenal ulcer abdominal pain is after 90 to 3 hours of meal
2. Gastric ulcer pain is just after food taking
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