DIAGNOSIS AND THERAPY OF PEPTIC ULCER Dijagnostika i terapija peptickog ulkusa

1. DIAGNOSIS AND THERAPY OF PEPTIC ULCERDijagnostika i terapija peptickog ulkusa Milorad Opacic Center of Interventional Gastroenterology, University Hospital Rebro Clinical Hospital Center, Zagreb, Croatia

2. Radiography in ulcer disease Sensitivity: Single contrast < 50% of DUs double contrast, compression, or hypotonic duodenography: 80 %of DUs GUs also varies as a function of technique Levine, MS. Role of the double-contrast upper gastrointestinal series in the 1990s. Gastroenterol Clin North Am 1995; 24:289.

3. Endoscopy in ulcer disease (UD) Sensitivity: location of the ulcer experience of the endoscopist Experienced endoscopists detect about 90 % GD lesions found by a second endoscopist, by radiography, or at surgery* *Cotton, PB, Shorvon, PJ. Analysis of endoscopy and radiography in the diagnosis, follow-up and treatment of peptic ulcer disease. Clin Gastroenterol 1984; 13:383. Dooley, CP, Larson, AW, Stace, NH, et al. Double-contrast barium meal and upper gastrointestinal endoscopy. Ann Intern Med 1984

4. Differentiation: benign gastric ulcer / cancer Benign gastric ulcer (GU) smooth, regular, rounded edges, flat, smooth ulcer base Cancer ulcerated mass nodular, clubbed, fused surrounding folds irregular or thickened margins

5. Differentiation: benign gastric ulcer / cancer Multiple biopsies The chance of malignancy > large GUs optimal number of biopsies 4 jumbo = 6 - 7 regular sized first biopsy- correct diagnosis in 70% four biopsy > 95% Seven biopsy > 98% Seven biopsy and cytology: 100% Graham, DY, Schwartz, JT, Cain, GD, et al. Prospective evaluation of biopsy number in the diagnosis of esophageal and gastric carcinoma. Gastroenterology 1982; 82:228.

6. Follow-up endoscopy to exclude malignant GU > 98% malignancies detected at initial evaluation risk of finding gastric cancer on follow-up: 0.8% - 4.3% If endoscopist confident that lesion was benign NPV for cancer 0.95 - 0.99 Kochman, ML, Elta, GH. Gastric ulcers — when is enough, enough? Gastroenterology 1993; 105:1583. Bustamante, M, Devesa, F, Borghol, A, et al. Accuracy of the initial endoscopic diagnosis in the discrimination of gastric ulcers: is endoscopic follow-up study always needed?. J Clin Gastroenterol 2002; 35:25. Hopper, AN, Stephens, MR, Lewis, WG, et al. Relative value of repeat gastric ulcer surveillance gastroscopy in diagnosing gastric cancer. Gastric Cancer 2006; 9:217.

7. Histology in ulcer disease first set of biopsies: dysplasia (?) Repeat biopsy ! missed sample carcinoma masquerading as benign ulcer

8. Ulcer disease; H. pylori testing  At endoscopy: biopsy (urease testing or histology) Negative ? second test (Breath or stool antigen testing) SS and SP of urease biopsy / breath testing: 90 and 95% NPV 99% PPV 67%

9. Natural history of UD  widely variable spontaneous healing recurrence within a year or two ( 50 - 80% )

10. Therapy of UD  General points: eradication of H. pylori in infected individuals antisecretory therapy withdraw of NSAIDs, cigarettes, and alcohol excess no firm dietary recommendations

11. Antisecretory therapy after HP eradication  Small or moderate size DU’s or GU’s: no additional therapy Complicated & increased risk DU’s or GU’s : maintenance of acid suppression follow-up endoscopy 4 to 12 wks after HP therapy stepping down to H2 receptor antagonist (?)

12. Therapy of HP negative UD  false-negative testing for HP consumption of NSAIDs DU COMPLICATED DU & GU another HP test endoscopy & biopsy urease test & histology THERAPY

13. Healing rates H2 ANTAGONISTS PPI cimetidine, ranitidine, omeprazole, esomeprazole famotidine, nizatidine lansoprazole, pantoprazole, rabeprazole DU DU 4 wks 70 - 80% 2 wks 63 - 93 % 8 wks 87 - 94% 4 wks 80 - 100 % .

14. Antacids and sucralfate  

15. Endoscopic follow up after initial therapy  Uncomplicated DU no need for further endoscopy GU no clear consensus to guide management repeat endoscopy with biopsy

16. Prepyloric and giant ulcers  Prepyloric ulcers different levels of acid secretion and the distribution of gastritis slower healing Giant ulcers  H2 receptor antagonists - slow healing and recurrences PPI’s: 12 wks – therapy of choice

17. Reccurent ulcer  Predisposing factors: HP infection regional inflammatory response poor healing bulb deformity gastric metaplasia in the duodenum NSAID use smoking

18. Maintenance therapy  Prevention of recurrence High-risk subgroups: history of complications frequent recurrences refractory, giant, or severely fibrosed ulcers Long-term maintenance therapy high-risk patients who fail H. pylori eradication

19. Maintenance therapy  Doses of H2 antagonists (ad bedtime) Ranitidine 150 mg Cimetidine 400 mg Famotidine 20 mg Nizatidine 150 mg PPI appropriate dose ? to be used if H2 failed ?

20. Maintenance therapy in high risk subgroups*  DU recurrence rate (12 mo) : H2 antagonists: 20 - 25% Placebo: 60 - 90% *data from largely HP-positive population

21. Maintenance therapy in high risk subgroups*  Highest risk of recurrence in first 3 - 6 mo of th. Recurrence similar as in pts on placebo if MT is stopped after 1 yr Uncomplicated recurrent disease: MT 2 yrs Complicated disease: MT 5 yrs *data from largely HP-positive population

22. Reccurent ulcer treatment  Maintenance therapy until cure of HPin high risk group in pts who fail HP eradication in pts with HP negative reccurent ulcers

23. Refractory ulcer  Etiology Persistent H. pylori infection NSAID use Smoking Impaired healing (inflammation, circulatory problems......... Acid hypersecretory states Impaired response to antisecretory agents Comorbidity (uremia, cirrhosis....)

24. Refractory ulcer  Treatment HP eradication followed by standard PPI therapy Endoscopy after 8 wks, repeat biopsy in GU 6 - 24 mo of sustained full dose antisecretory therapy maximal medical therapy before recommending elective surgery