Lec 2 - Peptic Ulcer Flashcards
(14 cards)
drugs can alter the balance towards healing and prevention of recurrence of ulcer by the drugs
by neutralization of secreted acid by antacids (define it) , mention classification
Are weak bases that react with gastric acid to form water and a salt to diminish gastric acidity
a- Systemic (sodium bicarbonate) and non systemic (aluminum, magnesium and calcium salts).
b- Fast acting (sodium bicarbonate, magnesium oxide or hydroxide, and magnesium carbonate) and slow acting (aluminum hydroxide and magnesium trisilicate).
c- According to potency (sodium bicarbonate > magnesium oxide or hydroxide > magnesium trisilicate > magnesium carbonate > aluminum hydroxide).
Note (MCQ)
1- decrease H. pylori colonization and stimulate endogenous PGE production (some cytoprotective properties).
2- calcium supplement for the treatment of osteoprosis.
3- is usually not a problem in patients with normal renal function, however, adverse effects may occur in patients with renal impairment.
4- inactive at a PH greater than 4
5- reduce pepsin activity.
6-may interfere with absorption of certain drugs as iron supplement, digoxin, tetracycline, and antifungal agents
1- Aluminum hydroxide
2- calicium carbonate preparation
3-Absorption of the Cations from
antacids (Mg,Al,ca)
4- Pepsin
5- Antacids
6- Antacids * so the patient either stop using these drugs or take it at least 2 hrs. after the antacids
Therapeutic Uses of Antacids :
- Mainly used to relieve ulcer symptoms and GERD especially in the 1st few days in the course of treatment with H2-receptor blocker.
- Large amount of antacids are shown to accelerate healing of duodenal peptic ulcer, and used as last line therapy for acute gastric ulcer but patient compliance is poor
Individual Antacids, Possibly MCQ
A. Magnesium Oxide, Hydroxide and trisilicate:
Magnesium oxide and hydroxide react quickly but cause diarrhea. Systemic acid-base balance is thus not significantly altered.
B. Aluminum Hydroxide:
Reacts with HCl to form AlCl3 which reacts with intestinal secretion to form insoluble salts especially phosphate. The chloride being released and reabsorbed, thus acid-base balance is not affected. It may cause constipation, hypophosphatemia.
C. NaHCO3
Reacts quickly with acids, short duration, it is absorbed causing systemic metabolic alkalosis. Na+ absorption may cause oedema, heart failure in patients with cardiac or renal disease and also caused belching and flatulence
D. Ca+ and Bismuth-Containing Antacids
They should avoided. Those containing Ca+ may cause: rebound acid hypersecretion, hypercalciemia, and alkalosis
what is Antacid combinations ?
a- Alginic Acid (Gaviscon):
b- Dimethicone: Added to antacids to reduce flatulence (anti-foaming agent).
drugs can alter the balance towards healing and prevention of recurrence of ulcer by the drugs by antigastrin agent ?
- Proglumide.
- Oxethazaine.
drugs can alter the balance towards healing and prevention of recurrence of ulcer by the drugs By enhancement of mucosal resistance by Prevent - mucosal resistance, reducing inflam. & healing existing ulcer). ?
A. Protection of the Base of Peptic Ulcer
B. Cytoprotection
C. Eradication of H. pylori by Antimicrobials
According to the enhancement of mucosal resistance by Prevent - mucosal resistance, reducing inflam. & healing existing ulcer). ?
A- Protection of the base of peptic ulcer
I. By Colloidal Bismuth (bismuth subsalicylate): 10mg bid 30 minute before breakfast and evening meal or two hour after.
II- Sucralfate
1- Mode of action of Colloidal Bismuth (bismuth subsalicylate):
2- Therapeutic uses
3- Adverse effects
1///- A. Selectivity chelates with protein material in the ulcer base forming a coating that protects it from adverse influence of acid, pepsin and bile.
B. It may also stimulate mucus secretion.
C. Bismuth has anti H. pylori action.
- Efficacy ≈ that of H2-receptor blockers (MCQ)
2-///- A. For benign gastric and duodenal ulcer.
B. It is also used for acute diarrhea and prevention of travellers diarrhea
3///- Darkening of the tongue, teeth and stool for liquid formulation.
Systemically may cause
encephalopathy and arthropathy
1- Mode of action of sucralfate
2- Therapeutic uses
3- Side effect
+ Drug Interactions of drug that protection of the base of the peptic ulcer :
1/// _This complex of aluminium hydroxide and sulphate sucrose in acidic environment of stomach
the aluminium moiety and the compound is released (-ve charged sucrose octasulphate)
binds electrostatically to the (+ve charged protein molecule of both normal and necrotic mucosa).
By forming complx gels with epithelial cells, it also binds to and inactivates pepsin and bile acids (ulcerogenic).
It increase endogenous PGs, mucus, and HCO3 secretion and enhances mucosal repair (angiogenesis and granulation tissue formation)
mucosal defence
prevent recurrence (long term maintenance).
2/// A. Chronic duodenal ulcer.
B. It is not effective for preventing or healing of NSAIDs-induced ulcers.
*Efficacy equals to that of H2-receptor blockers
*Maintenance treatment is effective of preventing relapse.
3/// _Side Effects: only constipation.
+ As it acts in acidic medium only, it should not be given with antacids, H2 antagonist, PPI, it interferes with absorption of ciprofloxacin, theophylline, digoxin, phenytoin, and amitriptyline because of its binding with them (like antacids).
According to the enhancement of mucosal resistance by Prevent - mucosal resistance, reducing inflam. & healing existing ulcer). ?
B- Cytoprotection (PGs and their Analogues)
A. Misoprostol: 200mg four time a day.
Is a synthetic analogue of PGE1, that enhances mucosal resistance by the same mechanism of PGs.
B- Enprostil, Arbaprostil are PGE2 derivative.
C- Rioprostil is synthetic PGE1
1- Mode of action of cytoprotection
2- Therapeutic uses
3- Side effect & contraindication
1/// _A. 1-Inhibits secretion of HCl by reducing histamine production,
2-reducing histamine stimulates adenylyl cyclase
3- decreasing cAMP levels in parietal cell
4-stimulates secretion of mucus and HCO3 (cytoprotective effect).
B. It maintains mucosal blood flow.
C. It prevents luminal H+ back diffusion to mucosa.
D. It enhances the rate of cell replication in the mucosa to hasten the repair of damaged epithelium.
PPIs may be as effective and better tolerated than misoprostol in prevention of NSAIDs-induced ulcer
2/// _A. Used for the treatment of chronic gastric and duodenal ulcer due to its inhibition of acid secretion (independent on cytoprotective action).
B. Also it is used for prevention of NSAIDs-induced ulcer (considered the drug of choice for this purpose, PPIs may be as effective and better tolerated).
3/// _Side Effects:
- Uterine contraction, dislodging of the fetus.
- Dose related diarrhea, and nausea.
Contraindications:
It is contraindicated in pregnant women because it may cause abortion
According to the enhancement of mucosal resistance by Prevent - mucosal resistance, reducing inflam. & healing existing ulcer). ?
C- Eradication of H. pylori by Antimicrobials
2- How can treat a patient with peptic ulcer who are H. pylori-positive?
It is accepted as a cause of ulcer because it is found that 70-90% of patients with peptic ulcer have antral gastritis. Eradication protects against relapse of peptic ulcer
2/// _Regimens of Eradication:
A/ we can treat him by using one of the following :
- The best treatment is by using proton pump triple therapy which consists of (first line therapy for 7 days):
a. PPI as omeprazole (2 X 20 mg) every 12 hourly or lansoprazole 2 X 30mg/bid or pantoprazole 2 X 40mg/bid = one drug (antisecretory).
b. Two of the following = 2 ABCs: clarithromycin 500mg 12 hourly and amoxicillin 1gm 12 hourly or metronidazole 400mg 12 hourly.
- We can use H2-receptor antagonist triple therapy but the first is better.
Second line therapy (quadruple) for 10-14 days:- (if failure of first line therapy).
- There is quadruple therapy used when PPI triple therapy is not successful and it consists of:
2 antibiotics (tetracycline 500mg (qid) + amoxicillin 1 gm or metronidazole 500mg bid) +
2 adjunctive: bismuth 220 mg (bid) + PPI or long-term maintenance therapy with acid suppression.
In case of treatment failure
Select retreatment regime after consideration of previous therapy and /or microbial sensitivities
Gastrointestinal tract & Management ?
Gastro-oesophageal reflux disorder (GERD): Presenting as heartburn or regurgitations of food. There is backflow of gastric acid and other contents of stomach into the esophagus due to dysfunction of sphincters at the gastro-oesophageal function.
Management
General & drug therapy
1- General (life style modification):
a- Weight reduction, stop smoking.
b- Raising the head of the bed by 15-20cm, don’t sleep after meal.
c- Avoid drug relax gastroesophageal sphincter as antimuscarinic, antihistaminic, antidepressant, muscle relaxant
2- Drug therapy:
a- Antacids.
b-Acid suppression as H 2-receptor antagonist, PPI.
c- Prokinetic drugs: as metoclopramide and domperidone
