Fauzi Yusuf
Gastroenterohepatologi Division Internal Medicine Department Syiah Kuala University/Zainoel Abidin Hospital
PEPTIC ULCER
Incidens in Western Contries: Female 4 15 % & Male 10 15 % Patient Problem: Suffer recurrency / relaps, loss in the works, cost of medication expensive Upper GI endoscopy in Cipto Mangunkusumo Hospital: The incidene of Peptic Ulcer: 6,93 7,10%; Duodenal Ulcer: Gastric Ulcer = 2:1
8 7 6 5 4 3 2 1 0
Leukemia AIDS NSAID-GI disease Melanoma Asthma Cervical cancer
Type of Prevalence of upper gastrointestinal disease (UGI) in dyspepsia cases, Internal Medicine Dept. Faculty of Medicine / Cipto Mangunkusumo Hospital and Zainoel Abidin Hospital Banda Aceh
Type of Disease
Normal
RSCM (1994)
28
RSUZA (2001/2002)
17,5
Gastritis/erosive Gastritis
Duodenitis Esophagitis Bile Reflux Gastritis
44,67
7,67 5,83 4,5
40,5
7,05 10,70 1,05
3,5 2,2
1,2 1 3,16
2,037 1,05
3,05 0,95 0,024
DEFINITION
Peptic Ulcer: Damage of mucosal layer/muscularis mucosa or deeper until submucosa of the stomach/duodenum, ulcer edge surounded by acute and chronic inflamatory cells; the diameter 5 mm Erosion: damage < 5 mm and the depth not over than muscularis mucosa
H.pylori
Young more often than elderly Men more often than woman Duodenal more than gastric Usually pain and or dyspepsia Surrounding mucosa inflammed (active chronic gastritis)
Scarpignato,1997
Possible
Concomitant infection with Cigarette smoking Alcohol consumption
H. pylori
AGGRESSIVE FACTORS
Acid + pepsin
Mucus layer Bicarbonate Surface epithelial cells Mucosal blood supply
H. pylori
AGGRESSIVE FACTORS
NSAIDs
Acid + pepsin
H. pylori
Mucus layer
Bicarbonate
None Dyspeptic Symptom: Epigastric Pain, Nausea, Vomiting,anorexia, epigastric discomfort, etc Epigastric Pain Episodic, Nocturnal, Pain-Food- Relief pattern can be pointed at Loss of body weight Hematemesis and Melena
2. Physical Examination: Epigastric Pain, bloating, succusion splash (obstruction), anemia (bleeding), Perforation symptom
NON-INVASIVE
Urea Breath Test Serum serology for Hp antibody test Whole blood serology for Hp antibody test Saliva Assay for Hp antibody test Helicobacter Pylori stool antigent (HpSA) test
MANAGEMENT
General/supportif Stop/Inhibit aggressive factor Increase the defensive factor Other treatment Threat the complication Avoid ulcer relaps/recurrence
Age over 45 years old Alarm signs Therapy failure History of Peptic ulcer + Complication Patient enquery The use of aspirin or NSAID Abnormality in Upper GI X-Ray (OMD)
Tripple therapy (1 or 2 weeks): PPI + Amoxicillin + Clarithromycin PPI + Metronidazole + Clarithromycin PPI + Metronidazole + Tetracyclin (Alergy to clarithromycin) Quadrupple therapy ( 1 or 2 weeks): If fail to therapy combination 3 drugs:
High resistency area: PPI + Bismuth + Tetracyclin + Metronidazole PPI 2 x/d: Omeprazole/Esomeprazole 20 mg, Lansoprazole 30 mg, Pantoprazole 40 mg, Rabeprazole 10 mg Amoxicillin 2 x 1000 mg/d, Clarithromycin 2 x 500 mg/d, metronidazole 3 x 500 mg/d, tetracyclin 4 x 250 mg/d, Bismuth 4 x 120 mg/d
CONCLUSIONS
The three aims of ulcer treatment are : Symptom relief, Healing of the ulcer, prevention of recurrence. For H Pylori Positive, Eradication therapy should be given to prevent ulcer recurrence For optimal ulcer healing, NSAIDS should be stop is possible.