pud definition
PUD is a defect in the gastric or duodenal mucosal wall that extends through the muscularis mucosa into the deeper layers of the submucosa
The most common causes of PUD are:
H. pylori infection
Use of NSAIDs
Stress-related mucosal damage
complication of pud are
GI bleeding,
perforation, and obstruction.
Factors that influence the incidence and prevalence of H. pylori infection:
age
ethnicity
sex
geography & socioeconomic status
h pylori is transmitted through?
it cause gastrtic or pud?
The infection normally resides in the stomach and is transmitted through ingestion of fecal-contaminated water or food.
H. pylori causes gastritis in the infected people, but < 10% develop symptomatic PUD.
Risk factors for ulcers & GI complications related to NSAIDs use:
- Age older than 60 years
- Multiple NSAID use (e.g., low-dose aspirin plus another NSAID)
- Duration of NSAID use (> 1 month)
- High-dose NSAID use
- Concomitant use of corticosteroid, SSRI or anticoagulant
- Previous PUD or PUD complications (bleeding / perforation)
- Cardiovascular disease and other comorbid conditions
- Smoking
- Alcohol ingestion
Physiologically stressful situations that lead to Stress ulcer include:
Sepsis
Organ failure
Prolonged mechanical ventilation
Thermal injury (burns)
Surgery
Stress-Related Mucosal Damage (Stress-ulcer) occurs most frequently in critically ill patients due to mucosal defects caused by gastric mucosal ischemia and intraluminal acid.
The harmful effects of smoking on the gastric mucosa:
- Increased pepsin secretion
- Duodeno-gastric reflux of bile salts
- Elevated levels of free radicals
- Reduced prostaglandin-2 (PG2) production
*
These harmful effects of smoking results in decreased mucus and bicarbonate secretion.
the pain symtoms of ulcer
Epigastric pain
1. duodenal ulcers typically occurs 1 to 3 hours after meals or at night and is often relieved by food.
2. gastric ulcers is often aggravated by food.
Abdominal pain may be described as burning or a feeling of discomfort.
sign and symptoms of ulcer
- Symptoms range from mild epigastric pain to life-threatening GI complications.
- Patients may also complain of heartburn, belching, bloating, nausea, or vomiting.
- No sign or symptom differentiates H. pylori- versus NSAID-induced ulcer.
- Weight loss may be associated with nausea and vomiting.
- Complications such as bleeding, perforation, or obstruction may occur.
diagnose or identify the presence of ulcer
Radiologic and/or endoscopic procedures are usually required to document the presence of ulcers.
Endoscopic diagnosis involves extraction of gastric tissue samples that are subsequently tested for H. pylori.
Testing for H. pylori infection
is indicated in patients with active PUD, history of PUD, and gastric mucosa associated lymphoid tissue lymphoma.
Histology is the standard identification method, but culture, PCR, and the rapid urease test can also identify H. pylori in tissue samples.
invasive and non invasive h pylori investigation of ulcer
invasive:
1. histology
2. culture
3. urease test
non invasive
1. breath test
2. serological test
3. stool antigen test
rapid urease test
- peel label
- place biopsy
- reseal label
- wait 1 hour
- check result
+ pink
_ yellow
desired outcome of treatment of pud
- Resolve symptoms
- Reduce acid secretion
- Promote epithelial healing
- Prevent ulcer-related complications
- Prevent ulcer recurrence
- For h. pylori–related PUD, eradication of H. pylori is an additional outcome.
Non-pharmacological Treatment
for acute bleeding due to pud
For patients with acute GI bleeding, endoscopic intervention can be achieved using contact thermal therapy, mechanical therapy using clips, or epinephrine injection followed by either thermal or mechanical therapy.
Treatment of H. pylori–Associated Ulcers
Eradication therapy with a PPI-based 3 drugs for all patients active ulcer or a history of either ulcer or ulcer-related complication.
clarithromycin 500mg+ metronidazole 500mg + omeprazole 20mg twice daily
(Bismuth subsalicylate posttasium 140mg + metronidazole125 + tetracycline125 ) three time daily + omeprazole 20mg twice daily
Treatment of NSAID-Induced Ulcers
- discontinue the NSAIDs and replace (e.g. Paracetamol), if possible.
- who cannot discontinue NSAIDs; PPIs or Misoprostol
- ppi are preffered strongest acid suppresor
ppi> misoprostol> h2ras
low cv risk and
1. high gi risk
2. moderate gi risk
3. low gi risk
1. high: cox2 + PPI or misoprostol
2. moderate: NSAID + PPI or misoprostol
3. low : NSAID
high cv risk and
1. high gi risk
2. moderate gi risk
3. low gi risk
1. high: no cox2 or naproxen
2. moderate: naproxen + ppi or misoprostol
3. low : naproxen+ ppi or misoprostol
ppi or misorpostrol fro nsaid related ulcer
PPIs: Drugs of choice for healing and secondary prevention of NSAID-induced ulcers.
Misoprostol appears to be as effective as PPIs; however, it necessitates several doses per day, and it is poorly tolerated because of the high incidence of diarrhea and abdominal pain.
The indications for stress ulcer prophylaxis in ICU patients are:
- Mechanical ventilation for longer than 48 hours
- History of (GI) ulceration or bleeding within 1 year of admission
- Head trauma or Glasgow Coma Score of ≤ 10 (or inability to obey simple commands)
- Thermal injuries more than 35% of body surface area
- Multiple traumas with an injury severity score of 16 or more
- Partial hepatectomy
- Transplant patients in the ICU perioperatively
- Spinal cord injuries
- Presence of two of the following risk factors:
Alarm symptoms
- evidence of bleeding (e.g., anemia, heme-positive stool, melena),
- perforation (e.g., severe pain),
- obstruction (e.g., vomiting),
- malignancy (e.g., weight loss, anorexia).
