Chapter 50: Peptic Ulcer Disease and Related Disorders

KEY CONCEPTS

• Psychological stress, cigarette smoking, nonsteroidal anti-inflammatory drug (NSAID) use, and certain foods/beverages can exacerbate ulcer symptoms and should be avoided.

• Eradication of Helicobacter pylori (H. pylori) is recommended in all patients who test positive, especially in those patients with an active ulcer, a documented history of a prior ulcer, or a history of ulcer-related complications.

• The selection of an H. pylori eradication regimen should be based on several factors, including: efficacy, safety, antibiotic resistance, cost, and the likelihood of medication adherence. The recommended initial treatment options with the strongest level of evidence include bismuth quadruple and concomitant therapy, both administered for 10 to 14 days. Clarithromycin-based triple therapy is no longer preferred due to increasing resistance and reduced eradication rates.

• When first-line therapy fails, salvage treatment for H. pylori should contain different antibiotics due to potential resistance. Patients with reported penicillin allergy should be considered for penicillin skin testing after failing first-line therapy since many can safely be treated with amoxicillin containing salvage regimens.

• PPI co-therapy reduces the risk of NSAID-related gastric and duodenal ulcers and is at least as effective as recommended dosages of misoprostol and superior to the histamine-2 receptor antagonists (H2RAs).

• Standard PPI dosages and a nonselective NSAID are as effective as a selective cyclooxygenase-2 (COX-2) inhibitor in reducing the risk of NSAID-induced ulcers and upper gastrointestinal (GI) complications.

• Patients with peptic ulcer disease (PUD), especially those receiving H. pylori eradication or misoprostol co-therapy, require patient education regarding their disease and drug treatment to successfully achieve a positive therapeutic outcome.

• Treatment for severe peptic ulcer bleeding after appropriate endoscopic treatment includes IV administration of a PPI loading dose followed by a 72-hour continuous infusion.

• Coagulopathy and respiratory failure requiring mechanical ventilation are two of the highest risk factors for developing stress-related mucosal bleeding (SRMB). Prophylactic drug therapy should be administered to critically ill patients with one of these complications.

• Since there are limited data to support the selection of a PPI over an IV H2RA for SRMB prophylaxis, agent selection should be based on appropriate individual patient characteristics (eg, nothing by mouth, presence of nasogastric tube, thrombocytopenia, renal failure).

Preclass Engaged Learning Activity

Conduct a brief internet search of the most commonly available nonprescription proton pump inhibitor (PPI) medications. Construct a table including the drug name, brand name(s), dosage, and potential side effects. Then, make a brief list of test results and symptom information you would want to collect if a patient whose care you were managing was taking a PPI. This activity is intended to get you familiar with the types of PPIs available to consumers without a prescription, as patients with peptic ulcer disease (PUD) could already ...