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Dx Peptic Ulcer Treatment: Read more..

Peptic Ulcer

The Merck Manual Home Edition
"A peptic ulcer is a round or oval sore where the lining of the stomach or duodenum has been eaten away by stomach acid and digestive juices.

Peptic ulcers can result from an infection with Helicobacter pylori or from drugs that weaken the lining of the stomach or duodenum. Discomfort caused by ulcers tends to come and go.

The diagnosis is based on symptoms of stomach pain and on the results of an examination of the stomach by using a flexible viewing tube (endoscopy).

*Antacids and other drugs are given to reduce acid in the stomach, and antibiotics are given to eliminate Helicobacter pylori.
*Ulcers penetrate into the lining of the stomach or duodenum (the first part of the small intestine). Gastritis may develop into ulcers.

The names given to specific ulcers identify their anatomic locations or the circumstances under which they developed. Duodenal ulcers, the most common type of pepticulcer, occur in the first few inches of the duodenum. Gastric ulcers, which are less common, usually occur along the upper curve of the stomach. Marginal ulcers can develop when part of the stomach has been removed surgically, at the point where the remaining stomach has been reconnected to the intestine. Stress ulcers, like acute stress gastritis, can occur as a result of the stress of severe illness, skin burns, or trauma. Stress ulcers occur in the stomach and the duodenum.

Ulcers develop when the normal defense and repair mechanisms of the lining of the stomach or duodenum are weakened, making the lining more likely to be damaged by stomach acid.

By far, the two most common causes of pepticulcer are infection of the stomach with Helicobacter pylori bacteria and use of certain drugs.
*Before current treatments for Helicobacter pylori infection were used, these bacteria were present in nearly 90% of people with duodenal ulcers and in 75% of people with stomach ulcers. Currently, the percentage is lower, about 50 to 75%.
*Many drugs, especially aspirin, other nonsteroidal anti-inflammatory drugs (NSAIDs), and corticosteroids, irritate the stomach lining and can cause ulcers. However, most people who take NSAIDs or corticosteroids do not develop peptic ulcers. Regardless, some experts suggest that people at high risk of developing peptic ulcers should use a type of NSAID called a coxib (COX-2 inhibitor), rather than one of the older types of NSAIDs, because coxibs are less likely to irritate the stomach (see see Coxibs (COX-2 Inhibitors)). However, studies have shown that coxibs appear to increase the risk of heart attack and stroke with long-term use and, therefore, caution should be taken with their use. Because of these complications, most doctors now use a standard NSAID plus a strong acid inhibitor (such as a proton pump inhibitor) for people at high risk of developing peptic ulcers.

People who smoke are more likely to develop a peptic ulcer than people who do not smoke, and their ulcers heal more slowly. Although psychologic stress can increase acid production, no link has been found between psychologic stress and peptic ulcers.

A rare cause of peptic ulcers is a type of cancer that causes excess acid production. The symptoms of cancerous ulcers are very similar to those of noncancerous ulcers. However, cancerous ulcers usually do not respond to the treatments used for noncancerous ulcers.

The typical ulcer tends to heal and recur. Thus, pain may occur for days or weeks and then wane or disappear. Symptoms can vary with the location of the ulcer and the person's age. For example, children and older people may not have the usual symptoms or may have no symptoms at all. In these instances, ulcers are discovered only when complications develop.

Only about half of the people with duodenal ulcers have the typical symptoms of gnawing, burning, aching, soreness, an empty feeling, and hunger. The pain is steady and mild or moderately severe and usually located just below the breastbone. For many people with a duodenal ulcer, pain is usually absent on awakening but appears by midmorning. Drinking milk or eating (which buffers stomach acid) or taking antacids generally relieves the pain, but it usually returns 2 or 3 hours later. Pain that awakens the person during the night is common. Frequently, the pain erupts once or more a day over a period of one to several weeks and then may disappear without treatment. However, pain usually recurs, often within the first 2 years and occasionally after several years. People generally develop patterns and often learn by experience when a recurrence is likely (commonly in spring and fall and during periods of stress).

The symptoms of gastric, marginal, and stress ulcers, unlike those of duodenal ulcers, do not follow any pattern. Eating may relieve pain temporarily or may cause pain rather than relieve it. Gastric ulcers sometimes cause swelling of the tissues (edema) that lead into the small intestine, which may prevent food from easily passing out of the stomach. This blockage may cause bloating, nausea, or vomiting after eating.

Complications of peptic ulcers, such as bleeding or rupture, are accompanied by symptoms of low blood pressure, such as dizziness and fainting.

What Are the Complications of Peptic Ulcers?
Most ulcers can be cured without complications. However, in some cases, peptic ulcers can develop potentially life-threatening complications, such as penetration, perforation, bleeding (hemorrhage), obstruction, and cancer.

An ulcer can go through (penetrate) the muscular wall of the stomach or duodenum (the first segment of the small intestine) and continue into an adjacent organ, such as the liver or pancreas. This penetration causes intense, piercing, persistent pain, which may be felt outside of the area involved—for example, the back may hurt when a duodenal ulcer penetrates the pancreas. The pain may intensify when the person changes position. If drugs do not heal the ulcer, surgery may be needed. Perforation:
Ulcers on the front surface of the duodenum, or less commonly the stomach, can go through the wall, creating an opening (perforation) to the free space in the abdominal cavity. The resulting pain is sudden, intense, and steady. The pain rapidly spreads throughout the abdomen. The person may feel pain in one or both shoulders, which may intensify with deep breathing. Changing position worsens the pain, so the person often tries to lie very still. The abdomen is tender when touched, and the tenderness worsens if a doctor presses deeply and then suddenly releases the pressure. (Doctors call this rebound tenderness.) Symptoms may be less intense in older people, in people taking corticosteroids, or in very ill people. A fever indicates an infection in the abdominal cavity. If the condition is not treated, shock may develop. This emergency situation requires immediate surgery and intravenous antibiotics.

Bleeding (hemorrhage) is a common complication of ulcers even when they are not painful. Vomiting bright red blood or reddish brown clumps of partially digested blood that look like coffee grounds and passing black or obviously bloody stools can be symptoms of a bleeding ulcer. However, small amounts of blood in the stool may not be noticeable but, if persistent, can still lead to anemia. Bleeding may result from other digestive conditions as well, but doctors begin their investigation by looking for the source of bleeding in the stomach and duodenum. Unless bleeding is massive, a doctor performs an endoscopy (an examination using a flexible viewing tube). If a bleeding ulcer is seen, the endoscope can be used to cauterize it (that is, destroy it with heat). A doctor may also use the endoscope to inject a material that causes a bleeding ulcer to clot. If the source cannot be found and the bleeding is not severe, treatments include taking ulcer drugs, such as histamine-2 (H2) blockers or proton pump inhibitors. The person also receives intravenous fluids and takes nothing by mouth, so the digestive tract can rest. If these measures fail, surgery is needed.

Swelling of inflamed tissues around an ulcer or scarring from previous ulcer flare-ups can narrow the outlet from the stomach or narrow the duodenum. A person with this type of obstruction may vomit repeatedly—often regurgitating large volumes of food eaten hours earlier. A feeling of being unusually full after eating, bloating, and a lack of appetite are symptoms of obstruction. Over time, vomiting can cause weight loss, dehydration, and an imbalance in body chemicals (electrolytes). Treating the ulcers relieves the obstruction in most cases, but severe obstructions may require endoscopy or surgery.

People with ulcers caused by Helicobacter pylori have 3 to 6 times the chance of developing stomach cancer later in life. There is no increased risk of developing cancer from ulcers that have other causes.

A doctor suspects an ulcer when a person has characteristic stomach pain. Sometimes the doctor simply treats the person for an ulcer to see whether the symptoms resolve, which suggests that the person had an ulcer that has healed.

Tests may be needed to confirm the diagnosis, especially when symptoms do not resolve after a few weeks of treatment, or when they first appear in a person who is over age 45 or who has other symptoms such as weight loss, because stomach cancer can cause similar symptoms. Also, when severe ulcers resist treatment, particularly if a person has several ulcers or the ulcers are in unusual places, a doctor may suspect an underlying condition that causes the stomach to overproduce acid.

To help diagnose ulcers and determine their cause, the doctor may use endoscopy (a procedure performed using a flexible viewing tube) or barium contrast x-rays (x-rays taken after a substance that outlines the digestive tract has been swallowed).

Endoscopy is usually the first diagnostic procedure ordered by a doctor. Endoscopy is more reliable than barium contrast x-rays for detecting ulcers in the duodenum and on the back wall of the stomach; endoscopy is also more reliable if the person has had stomach surgery. However, even a highly skilled endoscopist may miss a small number of gastric and duodenal ulcers. With an endoscope, a doctor can perform a biopsy (removal of a tissue sample for examination under a microscope) to determine if a gastric ulcer is cancerous and to help identify the presence of Helicobacter pylori bacteria. An endoscope also can be used to stop active bleeding and decrease the likelihood of recurring bleeding from an ulcer.

Barium contrast x-rays of the stomach and duodenum (also called a barium swallow or an upper gastrointestinal series) can help determine the severity and size of an ulcer, which sometimes cannot be completely seen during an endoscopy because it is further down the duodenum or hidden by a fold.

Because infection with Helicobacter pylori bacteria is a major cause of ulcers, antibiotics are often used. Sometimes bismuth subsalicylate is used in combination with antibiotics. Neutralizing or reducing stomach acid by taking drugs that directly inhibit the stomach's production of acid promotes healing of peptic ulcers regardless of the cause. In most people, treatment is continued for 4 to 8 weeks. Although bland diets may help reduce acid, no evidence supports the belief that such diets speed healing or keep ulcers from recurring. Nevertheless, it makes sense for people to avoid foods that seem to make pain and bloating worse. Eliminating possible stomach irritants, such as NSAIDs, alcohol, and nicotine, is also important.

Antacids do not effectively heal ulcers but they do relieve symptoms of ulcers by neutralizing stomach acid and thereby raising the pH level in the stomach. Their effectiveness varies with the amount of antacid taken and the amount of acid a person produces. Almost all antacids can be purchased without a doctor's prescription and are available in tablet or liquid form. However, antacids can interact with many different prescription drugs, so a pharmacist should be consulted about possible drug-drug interactions before antacids are taken.

Sodium bicarbonate (baking soda) and calcium carbonate, the strongest antacids, may be taken occasionally for fast, short-term relief. However, because they are absorbed by the bloodstream, continual use of these drugs may make the blood too alkaline, resulting in nausea, headache, and weakness. Therefore, these antacids generally should not be used in large amounts for more than a few days. These products also contain a lot of salt and should not be used by people who need to follow a low-sodium diet or who have heart failure or high blood pressure.

Aluminum hydroxide is a relatively safe, commonly used antacid. However, aluminum may bind with phosphate in the digestive tract, thereby depleting the body of calcium, reducing phosphate levels in the blood, and causing weakness and a loss of appetite. The risk of these side effects is greater in people with alcoholism and in people with kidney disease, including those receiving dialysis. Aluminum hydroxide may also cause constipation.

Magnesium hydroxide is a more effective antacid than aluminum hydroxide. This antacid acts fast and neutralizes acids effectively. Bowel movements usually remain regular if only a few tablespoons a day are taken; more than four doses a day may cause diarrhea. Because small amounts of magnesium are absorbed into the bloodstream, people with kidney damage should take magnesium hydroxide only in small doses. Many antacids contain both magnesium hydroxide and aluminum hydroxide.

Anyone who has heart disease, high blood pressure, or a kidney disorder should consult a doctor before selecting an antacid.

Acid-reducing Drugs:
Proton pump inhibitors are the most potent of the drugs that reduce acid production. Proton pump inhibitors promote healing of ulcers in a greater percentage of people in a shorter period of time than do histamine-2 (H2) blockers. They are also very useful in treating conditions that cause excessive stomach acid secretion, such as Zollinger-Ellison syndrome.

Histamine-2 (H2) blockers, such as cimetidine, famotidine, nizatidine, and ranitidine, relieve symptoms and promote ulcer healing by reducing the production of stomach acid. These highly effective drugs are taken once or twice a day. H2 blockers usually do not cause serious side effects. However, cimetidine is more likely to cause side effects, particularly in older people, in whom the drug may cause confusion. In addition, cimetidine may interfere with the body's elimination of certain drugs—such as theophylline for asthma, warfarin for excessive blood clotting, and phenytoin for seizures.

Zollinger-Ellison Syndrome: An Acid-Stimulating Cancer:
Zollinger-Ellison syndrome causes the stomach to produce too much acid. In this syndrome, a tumor, usually in the duodenum, pancreas, or adjacent structures, produces gastrin. Gastrin is a hormone that stimulates the stomach to produce large amounts of acid. About half of the tumors are cancerous (malignant). People with Zollinger-Ellison syndrome frequently develop many ulcers that recur despite treatment to control ulcer disease. They may also develop diarrhea that is difficult to control.

People with this disease typically have an elevated level of gastrin in their blood, which can be measured to make the diagnosis. Sometimes, testing involves giving the person a hormone called secretin. In people with Zollinger-Ellison syndrome, gastrin levels in the bloodstream greatly increase when secretin is injected into a vein. In addition, testing can reveal increased production of stomach acid. A number of tests can be performed in an attempt to find the tumor's location, including computed tomography (CT) scanning, endoscopic ultrasound, and radionuclide scanning.

Proton pump inhibitors help control the excess production of stomach acid. Surgery to remove the tumor can be curative. Even when not curative, surgery can reduce the tumor size, which in turn reduces the amount of acid produced by the stomach and prevents local complications, such as blockage of the intestine. Radiation and chemotherapy are not helpful. Although chemotherapy may reduce tumor size, it is not curative.

Miscellaneous Drugs:
Sucralfate may work by forming a protective coating in the base of an ulcer to promote healing. It works well on peptic ulcers and is a reasonable alternative to antacids. Sucralfate is taken 2 to 4 times a day and is not absorbed into the bloodstream, so it causes few side effects. It may, however, cause constipation, and in some cases it reduces the effectiveness of other drugs.

Misoprostol may be used to reduce the likelihood of developing stomach and duodenal ulcers caused by NSAIDs. Misoprostol may work by reducing production of stomach acid and by making the stomach lining more resistant to acid. Older people, people taking corticosteroids, and people who have a history of ulcers are at higher risk of developing an ulcer when they take NSAIDs and may also be potential candidates for misoprostol. However, misoprostol causes diarrhea and other digestive problems in more than 30% of people who take it. In addition, this drug can cause spontaneous abortions in pregnant women. Alternatives to misoprostol are available for people taking aspirin, NSAIDs, or corticosteroids. These alternatives, such as proton pump inhibitors, are just as effective for reducing the likelihood of developing an ulcer and cause fewer side effects."

Medications Used in Treatment:
1. Anticholinergics: Hyosyne® Symax® Hyomax®/hyoscyamine, Robinul®/glycopyrrolate, Pamine®/methscopolamine, propantheline
2. Anticholinergic/Benzodiazepine Combination: Librax®/ chlordiazepoxide-clidinium
3. Prevpac® is a combination of lansoprazole 30mg, amoxicillin 500mg and 500mg clarithromycin for treatment of H.Pylori.

Suggested Links:
*N.H.S. Choices (with Video)

Peptic ulcer disease remains a common condition, although reported incidence and prevalence are decreasing. This decrease may be due to a decrease in H. pylori-associated PUD. [Still] Peptic ulcer disease (PUD) is most commonly associated with Helicobacter pylori infection and the use of acetylsalicylic acid (ASA) and nonsteroidal anti-inflammatory drugs (NSAIDs)
Proton pump inhibitors are prescribed when the strongest treatment is needed. H. pylori infection must be treated with antibiotics. The most popular treatment for H. pylori infection includes a proton pump inhibitor to reduce acid production combined with two antibiotics, such as amoxicillin 500mg and clarithromycin 500mg ER given twice daily for 7 to 14 days. The combination of bismuth subsalicylate(a drug similar to sucralfate), tetracycline (an antibiotic), metronidazole(an antibiotic), and a proton pump inhibitor (portonix 40mg) daily is another popular option. However, this treatment requires people to take a total of four drugs up to 4 times a day for 7 to preferrably 14 days
*[Editor]: but is hundreds of dollars less expensive] than combination preparations.

*[Editor] When the acute H. pylori infection has cleared and there is no evidence of ulcer, consider the natural treatments for gastro-esophageal reflux disease (G.E.R.D.) that include Betaine HCl (to close the esophagus to reflux) and digestive enzymes (to digest the food). Long-term use of drug therapy that opens the egress from the stomach can become the cause of long-term digestive problems.

*[Editor] We conclude that: 1) major male (testosterone) and female (progesterone) sex hormones exhibit opposite effect on healing of preexisting ulcers in the oral cavity and stomach because testosterone markedly delayed while progesterone significantly accelerated this healing; 2) testosterone-induced delay in ulcer healing involves the fall in the gastric microcirculation at the margin of lingual and gastric ulcers and the excessive production and release of proinflammatory cytokine IL-1 beta; and 3) testectomy improves the gastric ulcer healing due to inhibition of gastric acid secretion and the rise in plasma gastrin, which exerts gastroprotective, trophic and ulcer healing action on the gastric mucosa".

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