Pharmacotherapy/Treatment Of Peptic Ulcer

Ulcer (peptic ulcer) is an open sore that develop on the inside lining of the stomach and upper portion of the intestine.

Type Of Peptic Ulcer

Peptic ulcer

There are two types of Ulcer. Both can affect one person. They are duodenal and gastric ulcer.
Duodenal Ulcer: are sores that occur on the inside of the upper portion of the small intestine (duodenum).
Gastric Ulcer: are sores that occur on the inside of the stomach.

Causes Of Ulcer

It is believe that the cause of ulcer is excess acid and pepsin secretion in the stomach. However, long term use of non-steroidal anti-inflammatory (NSAID) medication and a bacterium Helicobacter pylori (H. Pylori) are the scientifically proven cause of peptic ulcer. They cause an inflammation of the lining of the stomach and small intestine making it prone for stomach acid attack. There is a condition called zollinger-Ellison syndrome which cause increase secretion of acid. Chrohn disease is sore in the gastrointestinal tract that resemble ulcer.
Read Also: Pain medication peptic ulcer patient can use for minor pain

Risk Factor

Certain things can increase the chances of developing ulcer. They do not in effect cause peptic ulcer. They only increases the chances of developing ulcer in the presence of the main causes of ulcer. They are called risk factors which includes;

• Spicy food
• Smoking
• Excessive alcohol consumption
• Stress

• Other medication like anticoagulant, steroids (prednisolone) and selective serotonin re-uptake inhibitor (SSRI)

Sign And Symptoms

• Burning stomach pain
• Feeling fullness after eating very little food
• Bloating and excess gas in the stomach
• Belching
• Heartburn
• Nausea and vomiting (may include blood)
• Fatty food intolerance
• Dark blood in stool
• Trouble breathing
• Feeling faint
• Unexplained weight loss
• Loss of appetite

Diagnosis

Most persons with ulcer condition present with more than one sign and symptoms. However, to be certain it is ulcer, some test can be done in the laboratory by a qualified laboratory specialist. The test can determine the likely cause of the ulcer and best treatment plan.

Laboratory Test For Helicobacter Pylori (H pylori)

The presence of H. Pylori can determine the origin of the ulcer. The bacterium can be found in the blood and stool. But because blood test is not that accurate, more light will be thrown on the urea breath test, endoscopy and barium test.

Breath test is carried out by eating a radio active carbon. The H. Pylori is capable of breaking down the carbon to carbon dioxide in the stomach. The breath sample of the patient is collected over a bag and analysed. The presence of radio active carbon dioxide is an indication of the presence of the bacterium. The use of ulcer medication prior to the test can affect the result.
Endoscopy: this test is necessary for all types of ulcer cause by NSAID or H. Pylori. It involve inserting or passing a hollow tube fitted with a lens down the the stomach through the mouth. The medical doctor or laboratory specialist looks out for images of ulcer on the screen. A biopsy which involve collecting sample of the sore for further analysis may be recommend if there is any sign of injury along the lining of the stomach or intestines.
Barium test: is a simple way of taking images of the digestive tract for signs of ulcer. It involves a series of x-rays of the upper digestive tract. During the x-ray, the patient swallow a white liquid containing barium. The barium coats the digestive tract making ulcer sore visible in the x-ray images.

Pathophysiology Of Ulcer

Despite extensive research, the etiology of peptic ulcer disease remains unclear. Given the multiple processes that control acid and pepsin secretion and defense and repair of the gastroduodenal mucosa, it is likely that the cause of ulceration differs between individuals. Acid and pepsin appear to be necessary but not sufficient ingredients in the ulcerative process. It is clear that the majority of gastric ulcers and a substantial number of duodenal ulcers do not have increased gastric acid secretion. Recent research has focused more on protection and repair of the stomach and duodenum. NSAIDs cause a significant number of gastric and duodenal ulcers; this is probably due to inhibition of prostaglandin production with loss of its protective effects. In the absence of NSAIDs and gastrinoma, it appears that most gastric ulcers and all duodenal ulcers occur in the setting of H. pylori infection. Evidence is mounting in support of H. pylori as a necessary ingredient in the ulcerative process, similar to acid and pepsin. It is not known whether the bacteria or the accompanying inflammation is the more important factor in the pathophysiology. Although the pathophysiology of gastric ulcer and duodenal ulcer is similar, there are clearly differences between the two groups. Duodenal ulcer is typified by H. pylori infection and duodenitis and in many cases impaired duodenal bicarbonate secretion in the face of moderate increases in acid and peptic activity. These facts suggest the following process: increased peptic activity coupled with decreased duodenal buffering capacity may lead to increased mucosal injury and result in gastric metaplasia. In the presence of antral H. pylori, the gastric metaplasia can become colonized and inflamed. The inflammation or the infection itself then disrupts the process of mucosal defense or regeneration resulting in ulceration. A cycle of further injury and increased inflammation with loss of the framework for regeneration may then cause a chronic ulcer. Gastric ulcer often occurs with decreased acid-peptic activity, suggesting that mucosal defensive impairments are more important. The combination of inflammation, protective deficiencies, and moderate amounts of acid and pepsin may be enough to induce ulceration. Many questions remain in understanding the pathophysiology of peptic ulcer disease. The physiology and pathophysiology of mucosal regeneration and the mechanisms by which H. pylori and inflammation disrupt normal gastroduodenal function will be fruitful areas of future investigation.

Pharmacotherapy/Treatment Plan

The cause of ulcer will determine the best treatment plan. Both types of ulcer can be treated with same drugs and lifestyle modification.

Ulcers Caused By H. Pylori

To treat ulcer cause by this bacterium, it is important to get rid of the bacterium to reduce healing time. There are some antibiotics that are effective against H. Pylori. However, the subceptibility to each antibiotics varies from region to region. For places like Nigeria, amoxicillin, metronidazole, clarithromycin and tinidazole are quiet effective in eliminating this bacteria from the body. Others that are of therapeutic benefits include levofloxacin and tetracycline.
Using a single antibiotic may not produce a 100% cure rate. It is recommended to use two or three to achieve good result. Combining amoxicillin and metronidazole has produce some positive results as well as clarithromycin and tinidazole. The antibiotics need to be taken for two weeks.
In addition to antibiotic, there are other drugs that should be added to it. These are called ulcer drugs.

Immediate-release amoxicillin:

-Dual Therapy: 1 g orally every 8 hours for 14 days in combination with lansoprazole

-Triple Therapy: 1 g orally every 12 hours for 14 days in combination with clarithromycin and lansoprazole

Immediate-release Triple therapy:

-In combination with lansoprazole and amoxicillin: Clarithromycin 500 mg orally every 12 hours for 10 to 14 days

-In combination with omeprazole and amoxicillin: Clarithromycin 500 mg orally every 12 hours for 10 days

Clarithromycin Dual therapy:

-In combination with lansoprazole or omeprazole: Clarithromycin 500 mg orally every 8 hours for 14 days

-In combination with ranitidine bismuth citrate: Clarithromycin 500 mg orally every 8 to 12 hours for 14 days

Omeprazole 

Dual therapy: 40 mg orally once a day, taken concomitantly with clarithromycin

-Duration of therapy: 14 days

Triple therapy: 20 mg orally 2 times a day, taken concomitantly with amoxicillin and clarithromycin

-Duration of therapy: 10 days

Ulcer Cause By NSAID

The drugs use here can be added to antibiotics use for treating ulcer cause by the bacteria H. Pylori. They include;

Antacid

That are base and help to neutralise the stomach acid thereby reducing it's corrosive effect on the stomach and intestines lining. This medication is used to treat the symptoms of too much stomach acid such as stomach upset, heartburn, and acid indigestion. It is also used to relieve symptoms of extra gas such as belching, bloating, and feelings of pressure/discomfort in the stomach/gut. They do not treat ulcer. They offer instant relieve. These drugs have the ability to render other drugs worthless. They should not be given along with other drugs. This product may react with other medications (including digoxin, iron, pazopanib, tetracycline antibiotics, quinolone antibiotics such as ciprofloxacin). They should be given hours apart. They are not to be given with food. This is because they can reduce the stomach acid thereby increasing the chances of infection as the acid is no longer in the stomach to destroy bacteria that comes along with food. Also, the ulcer effects comes when the stomach is empty. Taking it when the stomach is full is like a waste because the food will absorb the acid. They include sodium bicarbonate, magnesium trisilicate, aluminum hydroxide, magnesium hydroxide, etc. Their side effects include diarrhea, vomiting, constipation, etc. Other beneficial compounds are simethicone and simethicone which reduce stomach gas during bloating and sodium alginate which had affinity for ulcer sore coating it and protecting it from the effect of stomach acid.

Liquid antacids usually work faster/better than tablets or capsules.  It does not prevent acid production. If you are taking the chewable tablets, chew thoroughly before swallowing, then drink a full glass of water. If you are using the liquid form of this medication, shake the bottle well before pouring each dose. Take on empty stomach.

Proton Pump Inhibitor (PPI)
These agents can block the production of acid in the stomach. They do this by blocking the action of the parts of the cells that produce acid. They include Omeprazole, esomeprazole, lansoprazole, pantoprazole, etc.

Omeprazole 20 mg is given orally once a day 30 minutes before food. The time it takes to start working (stop production of acid) is 30 minutes. This prevent the stomach from producing acid when eating. Taking the drug after eating cannot prevent production of acid when eating.

-Duration of therapy: 4 weeks
Histamine 2 inhibitor
These agents reduce the amount of stomach acid release into the digestive tract which relieve ulcer pain. They include ranitidine, famotidine, cimetidine, nizatidine. The dosing and side effects are similar to that of proton pump inhibitors. They are also taking 30 minutes before food.
Cytoprotective Agent
These agent protect the tissue that line the stomach and small intestine. Most of them are added to NSAID to help protect the stomach from the effect of the NSAIDS. An example is misoprostol.

Lifestyle Modification

There are risk factors which we have discussed earlier. These risky lifestyle must be stopped for ulcer healing to be effective. Most of these risk factors worsen ulcer and increase healing time. They are;
NSAID: It is necessary to switch from NSAID to other options with less ulcer risk e.g acetaminophen. If it is not possible, NSAID can be used with ulcer drugs with advise to eat before use. Some recent publications suggest the use of celecoxib 200mg every 12 hour as suitable pain medicine not for ulcer but Dorothee pain condition.
Diet: a healthy diet can go a long way in alleviating the ulcer. Eat small quantity of food at each sitting and frequently. Avoid eating much at a go less frequently. Eat less spicy food and more of fruit containing vitamin A and C as these help in boosting healing of the ulcer. Probiotics is another good option as it helps to fight off infection during the period antacid is being use. Milk may provide a temporary sensational relieve for ulcer pain. However, it stimulate the body to release acid. This can cause the acid to burn the ulcer more. Lastly, avoid fried, hot and/or cold food. Avoid caffeine containing food such as coca cola, Pepsi, coffee, fearless, etc.
Read Also: The Causes Of Peptic Ulcer
Stress: stress worsens symptoms of ulcer. No proven evidence yet but it is believe that the link is due to not taking care of oneself during stressful period. A good way to cope with the stress can help.
Alcohol: alcohol can irritate and erode the mucous lining in the stomach and intestines causing inflammation and bleeding.

Refractory Ulcer

Treatment with ulcer medication last a period of 8 weeks. Ulcer that does not heal after this period is referred to as refractory ulcer. The cause of refractory ulcer is usually due to non-adherence to medication, resistant of H. Pylori to medication, tobacco use, NSAID and alcohol.

Complications Of Untreated Ulcer

Untreated Ulcer causes severe pain. The pain can be due to bleeding form the site. Perforation of the site can occur in severe cases. This can lead to leakage of undigested food and bacteria into the sterile abdominal cavity which can cause more infection. Blockage of the small intestine due to the inflammation of the duodenal ulcer can cause feeling full and indigestion.

Prevention

It is not clear how we get helicobacter pylori. There is a theory that it is transmitted from human to human through the food we eat and water we drink. It is more common with elderly persons. It is good to observe personal hygiene to avoid the infection.
As for NSAID, it is best to avoid or reduce the use of NSAID. NSAID can be use with food and or cytoprotective agents.
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