Barium StudiesStill commonly used as a first test for

documenting an ulcer80% sensitivity : single contrast barium study90% sensitivity: double contrast barium studySensitivity is low for small ulcers (<0.5 cm)Duodenal ulcers appear as a well demarcated

crater most often seen at the bulbGastric ulcers may either be benign or

malignant

Barium StudiesBenign gastric ulcer appears as a discrete

crater with radiating mucosal folds originating from the mucosal margin

Ulcers >3 cm are more often malignant

Radiographic studies that show a gastric ulcer must be followed by endoscopy and biopsy.

Fauci, et. al. Harrison’s Principles of Internal Medicine, 17 th ed.

EndoscopyMost sensitive and specific Direct visualization of the mucosaPhotographic documentation of the defectTissue biopsy to rule out malignancy or H.

pylori.Helpful in identifying lesions too small to

detect by radiographic examination, evaluation of atypical radiographic abnormalities, or to determine if an ulcer is a source of blood loss

Fauci, et. al. Harrison’s Principles of Internal Medicine, 17 th ed.

Detection of H. pyloriNON-INVASIVE

Serology Detection of antibodies in the serum

Urea Breath Test Simple, rapid, early follow up

Stool antigen Sensitive, specific, and inexpensive

Fauci, et. al. Harrison’s Principles of Internal Medicine, 17 th ed.

Detection of H. pyloriINVASIVE (Endoscopy/Biopsy required)

Rapid urease Simple, false negative with recent use of PPIs,

antibiotics, or bismuth compounds

Histology Provides histologic information

Culture Time-consuming, expensive

Fauci, et. al. Harrison’s Principles of Internal Medicine, 17 th ed.

ObjectivesPain reliefHealingPrevention of complicationsPrevention of recurrences

AntacidsRarely used as a primary therapeutic agents

but are instead used for symptomatic reliefMixture of aluminum hydroxide and

magnesium hydroxideEg. Maalox, Mylanta

Fauci, et. al. Harrison’s Principles of Internal Medicine, 17 th ed.

H2 Receptor AntagonistsInhibit basal and stimulated acid secretionOften used for treatment of active ulcers (4-6

weeks) in combination with an antibiotic directed at eradicating H. pylori.

Eg. Cimetidine, Ranitidine, Famotidine, Nizatidine

Fauci, et. al. Harrison’s Principles of Internal Medicine, 17 th ed.

Proton Pump InhibitorsSubstituted benzimidazole derivatives that

covalently bind and irreversibly inhibit H+K+-ATPase

Eg. Omeprazole, Esomeprazole, Lansoprazole, Rabeprazole, Pantoprazole

Fauci, et. al. Harrison’s Principles of Internal Medicine, 17 th ed.

Cytoprotective AgentsSucralfate

Insoluble in waterViscous paste within the stomach and duodenum,

binding primarily to sites of active ulceration

Bismuth-containing compoundsUlcer coating; prevention of further pepsin/HCl-

induced damage; binding of pepsin; and stimulation of PGs, bicarbonate, and mucous secretion

Prostaglandin AnaloguesEnhancement of mucosal defense and repairEg. Misoprostol

Fauci, et. al. Harrison’s Principles of Internal Medicine, 17 th ed.

THERAPY FOR H. pyloriEradication of H. pylori is the primary goal

DRUG DOSE

TRIPLE THERAPY

1. Bismuth subsalicylate plus Metronidazole plus

Tetracycline

2. Ranitidine bismuth citrate plus Tetracycline plus

Clarithromycin or Metronidazole

3. Omeprazole (lansoprazole) plus Clarithromycin plus

Metronidazole or Amoxicillin

2 tabs qid250 mg qid500 mg qid

400 mg bid500 mg bid500 mg bid

20 mg bid (30 mg bid)250 or 500 mg bid500 mg bid1 g bid

DRUG DOSE

QUADRUPLE THERAPY

OmeprazoleBismuth subsalicylateMetronidazoleTetracycline

20 mg (30 mg) daily2 tablets qid250 mg qid500 mg qid

Fauci, et. al. Harrison’s Principles of Internal Medicine, 17 th ed.