1. No category

Management of Peptic
Ulcer Disease
Dr Chau Chun Han
LMCHK FRCS FHKAM
Evolutions in the Last Millennium
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Helicobacter Pylori (HP)
Therapeutic endoscopy
Minimally invasive surgery
Peptic Ulcer (PU)
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Gastric ulcer (GU)
Duodenal ulcer (DU)
Anastomotic ulcer
Epidemiology
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Significantly decline since 1960s
Fall in the prevalence of HP infection
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Increase in elderly (>60), particularly females
NSAID used for arthritis, ischaemic heart
disease and cerebrovascular disease
Etiology
Old
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No acid no ulcer
Idiopathic
Stress
Smoking
Spicy food
New
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Helicobacter Pylori
NSAID
Crohn’s disease
Gasrtrinoma
Hyperparthyroidism
Helicobacter Pylori
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Barry Marshall 1982
Gram negative
spirochaetal bacterium
Split urea to form
ammonia
Invade gastric mucosa
Helicobacter Pylori
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50% population infection rate
Chronic active gastritis 100%
DU 90%, GU 80%
10-20% with HP will develop PU, 4-10X
Type I/II, vacuolating toxin (Vac A) and
cytotoxin-associated protein (Cag A)
Cag A positive HP strains related to DU
HP & Diseases
H. Pylori & Peptic Ulcer
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Acid hypersecretion in DU
Acid hyposecretion in GU
Acid normal secretion in normal HP positive
population
Pathogenesis of H. pylori
Diagnosis of H. Pylori
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Gastric biopsy histology
CLO test
Urea breath test
Serology
HP antibody in saliva
HP antigens in stool
Rapid urine test
Clinical Features of PU
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30% asymptomatic
Upper abdominal pain
Dyspepsia
Vomiting
Anaemia
Haematemesis / melaena
Peritonitis
GU & DU
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GU
Postprandial pain
Vomiting
Haematemesis > Melaena
Afraid to eat
Lives on milk and fish
Loses weight
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DU
Hunger pain
No vomiting
Melaena > Haematemesis
Good appetite
Eats almost anything
No weight loss
Complications
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Bleeding: anaemia, melaena, haematemesis
Obstruction: vomiting, dysphagia, weight loss
Perforation: pain, peritonitis
Carcinoma in chronic gastric ulcer
History
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NSAID / Aspirin
Smoking
Previous history of PUD
Family of Ca stomach
Investigations
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Endoscopy:
CLO test Biopsy in GU
Barium meal
Blood tests: haemoglobin, electrolytes
USG abdomen
Duodenal Ulcer
Gastric Ulcer
Treatment
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In the past, majority treated with antisecretory
drugs, elective surgery when medical treatment
failed
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The discovery of HP has revolutionised the
management of PUD
Treatment
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Lifestyle and dietary modification
Drugs
Operation
Lifestyle & Dietary Modification
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Less stress
Regular diet
Avoid NSAID
Quit smoking
Drugs
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Eradication of HP
Gastric acid neutrolizers - Antacids
Antisecretory
Cytoprotectives
Eradication of HP
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Established treatment of PUD since early 1990s
First line treatment
Triple therapy- 2 antibiotics and 1 PPI for 1 week
Clarithromycin
Amoxicillin
Nexium
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500mg
1g
20mg
80 – 90% eradication rate
BD
BD
BD
Treatment failure
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Low compliance
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Resistance of HP to antibiotics
Eradication of HP
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Resistance of Clarithromycin 7.8%, Amoxicillin 0%,
Metronidazole 39.2%
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Clarithromycin-based therapy still the first choice with
eradication rate of 92.6%
Gu Q,, Xia HH Digestion 2006
Esomeprazole vs Pantoprazole
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Prospective randomized control trial
ECA vs PCA
Eradication rate 95% vs 82%
Esomeprazole is an independent predictor of
eradication success
Alcohol drinking is an independent predictor of
eradication failure
Hsu PI, Lai KH Am J Gastroenterology 2005
Eradication of HP
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Second line therapy
One week quadruple therapy
Bismuth 120mg Tetracycline 500mg
Metronidazole 400mg QID, Nexium 20mg BD
80% eradication rate
Rescue therapy
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Twice daily 1 week course
Rifabutin 150mg , Amoxil 1g , Nexium 20 mg
Eradication rate 70 %
Expensive
Re-infection of HP
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Re-infection rate 7.6%-23.5%
58.8% same strain
Recurrent ulcer in re-infected group 22.9%-25.3%
Not related to age, sex, ulcer location or eradication
regimens
HP eradication only without ulcer
healing drugs ?
Systemic review and meta-analysis
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6 studies 862 patients
Ulcer healing rate in triple treatment 91%, with
prolonged PPI (2-4 weeks) 92%
Prolonging PPI therapy not necessary to induce ulcer
healing
Gisbert JP Alimentary Pharm & Therap 2005
Gastric Acid Neutrolizers - Antacids
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The first and historically most widely used drug
Inhibit the conversion of pepsinogen to pepsin
Fast onset of symptom relief
Frequent dose – 7 times a day
Antisecretory Drugs
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H2 antagonists
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Proton pump inhibitors
H2 Antagonists
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Inhibit the action of histamine at the H2
receptors of parietal cells
Reduce basal and food stimulated acid secretion
50-60% acid is blocked
Cimetidine (800mg), Famotidine (40mg),
Ranitidine(300mg)
Once daily dose at bedtime 6-8 weeks
Proton Pump Inhibitors (PPI)
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Block the final step in gastric acid secretion by
combining with hydrogen, potassium and
adenosine triphosphatase in the stomach lumen
95% acid is blocked
Omeprazole (20mg), Lansoprazole (30mg),
Esomeprazole (20mg)
Once daily dose at bedtime 4-6 weeks
Cytoprotectives
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Sucalfate (aluminum hydroxide + sucrose)
Form a paste to protect gastrointestinal mucosa
1 g QID
NSAID induced ulcer
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Common in long term user, 15-30% or 20-fold
Ibuprofen and Diclofenac are safer
Stop NSAID + H2 blocker/PPI
NSAID + PPI recurrence less 60-80%
COX2 inhibitor reduce risk by 50-60%
HP and NSAID
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Independent and synergistic risks for PUD
Meta-analysis
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Randomised control trials comparing eradication vs noneradication or PPI
5 studies 939 patients
Eradication of HP reduced risk of PU in NSAID users especially
new users
Maintenance PPI is more effective than eradication of HP in
preventing PU in NSAID users
Vergara M Alime Pharmaco & Thera 2005
Idiopathic ulcer
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4% of bleeding ulcer in HK
Can be healed by usual dose and duration of H2
blocker or PPI
70-90% annual recurrence rate
Annual recurrence rate reduced to 20-30% by
long term H2 blocker maintenance ( half of
treatment dose)
Bleeding Peptic Ulcer
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Commonest complication
35% require urgent surgery if treated
conservatively
5-10% require urgent surgery after therapeutic
endoscopy
Endoscopic Haemostasis
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Adrenaline injection (1: 10,000)
Heater probe
Haemoclip
Argon plasma coagulation (APC)
Fibrin glue injection
Adrenaline Injection + Heater Probe
Endoscopic Haemostasis
Adrenaline Injection
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Endoscopic injection of adrenaline for actively bleeding
ulcers: a randomised trail
Chung SCS, Leung JWC, Sung JY, Lo KK, Li AKC. BMJ 1988
Fewer emergency operations, less blood transfusion
and shorter hospital stay
Adrenaline Injection + Heat Probe
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Randomized comparison between adrenaline injection alone and adrenaline injection plus heat probe
treatment for actively bleeding ulcer
Chung SS, Lau JY, Sung JJ, Chan, AC, Lai CW, Ng ED. BMJ 1997
Adrenaline injection + heat probe better with shorter hospital stay and less surgical intervention
Adrenaline Injection + Heat Probe
Argon Plasma Coagulation
Adrenaline Injection + APC
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Randomised controlled trial comparing epinephrine injection plus heat probe
coagulation versus epinephrine injection plus argon plasma coagulation for
bleeding peptic ulcers
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Chau CH, Siu WT, Law BKB, Tang CN, Kwok SY, Luk YW, Lao WC, Li MKW. Gastronintest
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As effective as adrenaline injection + heat probe
Endosc 2003
Adr+HP
Adr+APC
P value
Number of Patient
97
88
Initial Haemostasis
95.9%
97.7%
0.68
Recurrent Bleeding
21.6%
17.0%
0.43
Emergency Surgery
9.3%
4.5%
0.11
Hospital Stay
8.2
7.0
0.38
Mortality
6.2%
5.7%
0.88
Nonhealing ulcer in 8 wks
21.6%
5.7%
0.03
Haemoclip
Operation for PUD
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The need for elective surgery markedly
decreased from 1980s to 1990s by 92% in HK
because of eradication of HP and therapeutic
endoscopy
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Various laparoscopic ulcer procedures
developed in 1990s
Operation
Indications
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Refractory ulcer
Complications
Bleeding
Perforation
Pyloric stenosis
Operation for PUD
Acid reduction surgery
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Vagotomy
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Gastrectomy
Refractory Ulcer
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DU
Highly selective vagotomy
Billroth II gastrectomy
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GU
Billroth I gastrectomy
4%
Eradication of HP
6-15 %
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Recurrent
15%
4%
Highly Selective Vagotomy (HSV)
Partial Gastectomy
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Billroth I gastrectomy
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Billroth II gastrectomy
Truncal Vagotomy and
Gastrojejunostomy (TV & GJ)
Minimally Invasive Surgery in PUD
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Elective surgery
Laparoscopic HSV for DU
Laparoscopic Billroth I gastrectomy for GU
Laparoscopic TV & GJ for pylori stenosis
Emergency surgery
Laparoscopic repair of perforated peptic ulcer
(PPU)
Laparoscopic TV & GJ
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For pyloric stenosis
Acid reduction and drainage procedure
Laparoscopic Vagotomy and gastrojejunostomy for
benign gastric outlet obstruction
Siu WT, Tang CN, Law BKB, Chau CH, Yau KK, Yang GPC, Li MKW
Jr of Laparoendosc & Advan Surg Techni 2002
Feasible with satisfactory perioperative and longterm outcome
Laparoscopic TV & GJ
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Laparoscopic Repair of PPU
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Commonest operation in PUD
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First reported in 1990
Laparoscopic Repair of PPU
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Laparoscopic repair for perforated peptic ulcer: A
randomized controlled trial
Siu WT, Leong HT, Law BKB, Chau CH, Li ACN, Fung KH, Tai YP, Li MKW. Ann of
Surg 2002
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Routine use of laparoscopic repair of perforated peptic
ulcer
Siu WT, Chau CH, Law BKB, Tang CN, Ha PY Li MKW. BJS 2004
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Therapeutic minilaparoscopy for perforated peptic
ulcer
Siu WT, Chau CH, Law BKB, Tang CN, Kwok SY, Li MKW. Jr of Laparoendosc & Advan
Surg Techni 2004
Lap vs Open repair of PPU
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Safe and reliable procedure with short operating time, less postoperative pain,
shorter hospital stay and earlier return to normal daily activities
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Siu WT, Leong HT, Law BKB, Chau CH, Li ACN, Fung KH, Tai YP, Li MKW. Ann of Surg 2002
Lap
Open
P value
Number of patient
63
58
Age
53.8
56.1
0.5
Size of perforation (mm)
5.2
4.7
0.52
Operation time (min)
42.0
52.3
0.025
Pain scores
3.5
6.4
<0.01
Resume diet (day)
4
5
0.06
Hospital stay (day)
6
7
0.04
Return normal activities (day)
10.4
26.1
0.01
Laparoscopic Repair of PPU
Thank You