PUD and Laxatives

• Defensive factors of stomach and duodenum

  • Mucus
  • Bicarbonate
  • Blood flow
  • Prostaglandins
• Aggressive factors of stomach and deudenum

  • Helicobacter pylori
  • Nonsteroidal antiinflammatory drugs (NSAIDs)
  • Gastric acid
  • Zollinger-Ellison syndrome
  • Pepsin
  • Smoking
• Classes of antiulcer drugs that treat PUD

  • Antibiotics
  • Antisecretory agents
  • Mucosal protectants
  • Antisecretory agents that enhance mucosal defenses
  • Antacids
• Three ways to promote ulcerhealing

  1. Eradicate H. pylori (antibiotics)

  2. Reduce gastric acidity (antisecretory agents, misoprostol)

  3. Enhance mucosal defenses (sucralfate, misoprostol)
• Antibiotics

  Should be given to all patients with gastric/duodenal ulcers and documented H. pylori infection
• Mucus defensive factors

  secreted from GI mucosa

  forms barrier that protects underlying cells from acid and pepsin
• Bicarb defensive factors

  secreted from epithelial cells of stomach and duodenum

  trapped in mucus layer to neutralize H+ ions that penetrate the mucus
• Stomach and duodenum blood flow defensive factors

  adequate blood flow maintains mucosal integrity

  poor blood flow - ischemia, cell injury, vulnerability
• Prostaglandins defensive factors

  stimulate secretion of mucus and bicarb

  promote vasodilation

  additional protection by suppressing gastric acid
• H. Pylori

  gram negative bacillus

  colonize the stomach and duodenum by residing between the epithelial cells and mucus barrier - escapes destruction from acid and pepsid
• people can be asymptomatic and have H. Pylori
• H. Pylori causes PUD

  pts with PUD have H. Pylori

  duodenal ulcers more common with H. Pylori

  eradication promotes ulcer healing and minimizes ulcer recurrence
• how do NSAIDs cause ulcers?

  inhibit biosynthesis of prostaglandins

  decreases submucosal blood flow,

  suppress secretion of mucus and bicarb,

  promote secretion of gastric acid

  irritate gastric mucosa directly
• what is a requirement for peptic ulcer formation?

  gastric acid
• how does acid directly and indirectly cause ulcers?

  directly - injuring cells of the GI mucosa

  indirectly - activating pepsin
• what is Zollinger-Ellison syndrome?

  primary disorder of hypersecretion of acid that causes ulcers

  caused by tumor that secretes gastrin
• relapse rate for abx use and nonabx use

  relapse rate of nonabx use is high

  relapse rate of abx use is low
• to hasten healing and relieve symptoms of PUD with H. Pylori, what should be given with abx?

  Give an antisecretory agent with the abx to prevent recurrence
• what groups of pts are risk factors for ulcer development?

  > 60yrs old

  hx of ulcers

  high dose NSAID therapy
• what medication is preferred for pts with risk factors for ulcer development?

  Proton pump inhibitors - omeprazole
• what other PPI is effective for prophylatic of ulcers?

  Misoprostol - effective but causes diarrhea
• what medications are not recommended as prophylaxis for ulcer development?

  Antacids, Sucralfate, H2 Receptor blockers
• what medication if preferred with NSAID-induced ulcers?

  H2 receptor blockers and PPIs
• how do you evaluate healing of ulcer?

  monitoring relief of pain

  radiologic/endoscopic examination of ulcer site
• what test do you use to determine H. Pylori been eradicated?

  breath tests

  serologic tests

  stool test

  microscopic observation of stain biopsy
• Nondrug treatment for ulcer therapy

  Ulcer diet

  stop smoking

  avoid aspirin or NSAIDs if possible

  reduce stress and alchol
• how does ulcer diet help with PUD?

  bland foods with milk or cream does not accelerate healing

  change in frequency in meals - smaller portions help decrease fluctuations of intragatric pH

  no proof that caffeine beverages promote formation or healing
• what is the exception with Aspirin and PUD pts?

  the use of aspirin to prevent cardiacvascular disease

  in low doses only a small factor in PUD
• antibiotics are not recommended with pts asymptomatic with H. Pylori
• what antibiotics (CABMT) are used for treatment of PUD?

  Clarithromycin

  Amoxicillin

  Bismuth

  Metronidazole

  Tetracycline
• what two PUD abx have the lowest rate of resistance?

  Tetracycline - rare

  Amoxicillin
• Bismuth topically MOA

  disrupt cell wall of H. Pylori causing lysis and death

  inhibit urease activity and prevent H. Pylori adhering to gastric surface
• Bismuth side effects

  harmless black coloration to the tongue and stool

  long term - neurologic injury
• what PUD abx has most rate of resistance?

  Metronidazole (flagyl)
• what should you add to the abx regime?

  PPI or histamine-2 receptor antagonist
• what are the drug course dates for PUD?

  10 day course

  14 day course - slightly better
• what is the 2020 first line recommendation for PUD?

  14 day with quad therapy with PPI, amoxicillin BID, Metronidazole BID, and Clarithromycin BID
• what other first line treatment is recommended for PUD?

  Bismuth, PPI, Metronidazole, and Tetracycline
• Histamine-2 receptor antagonist (H2RA) MOA

  suppressing secretion of gastric acid

  Cimetidine, Famotidine, Nizatidine
• Cimetidine MOA

  reduces both volume of gastric juice and H+ ion concentration

  suppresses basal acid secretion stimulated by gastrin and acetylcholine