1

Peptic Ulcer And GERD

Krupanidhi College of Pharmacy,

Bangalore

Presented By- Bhavya Rewari M.Pharm. Ist YearDept. of Pharmacology

2

Peptic Ulcer Disease

3

Definition and Introduction Peptic ulcer is a chronic lesion that occurs in

any portion of the GIT (usually stomach) exposed to the aggressive action of acid-peptic juices

At least 98 % of peptic ulcers are in the upper portion of the duodenum

Peptic ulcer disease mainly comprises of painful sores or ulcers in the lining of the stomach or first part of the small intestine, called the duodenum

A peptic ulcer in the stomach is called a gastric ulcer. An ulcer in the duodenum is called a duodenal ulcer

4

Definition and Introduction It causes disruption of the mucosal integrity of the stomach,

duodenum, or both caused by local inflammation, which leads to a well-defined mucosal defect

Peptic ulcers are relapsing lesions that most often diagnosed in middle-aged to older adults

Duodenal ulcers are more frequent in patients with alcoholic cirrhosis, COPD and chronic renal failure

Normally, the lining of the stomach and small intestines is protected against the irritating acids produced in the stomach. If this protective lining stops working correctly and the lining breaks down, it results in inflammation (gastritis) or an ulcer.

5

Pathogenesis The imbalance between defensive

mechanism and aggressive factors (gastric acid and pepsin and H. pylori)

Defensive mechanism include;• Secretion of mucus by epithelial cells• Secretion of bicarbonate which act as buffer• Rapid gastric epithelial regeneration• Mucosal blood flow to sweep away hydrogen

ion

6

Pathogenesis Aggressive factors;• Secretion of gastric HCl from the parietal cells• Secretion of pepsin• Presence of H.pylori which survives in the

gastric mucosal layerAgents that increase the complications-• NSAIDs drug therapy• Cigarette smoking• Alcohol• Corticosteroids therapy

7

8

9

Signs and symptoms• Epigastric pain• The pain tends to be worse at night and occurs 1

to 3 hrs after meals• Nausea• Vomiting• Belching • Significant weight loss• Complications of hemorrhage occurs in one-third

patients• Feeling of fullness - unable to drink as much fluid• Pain or discomfort in the upper abdomen• Bloody or dark tarry stools

10

Some common causes Drinking too much alcohol Regular use of aspirin, ibuprofen, naproxen, or

other nonsteroidal anti-inflammatory drugs (NSAIDs

Smoking cigarettes or chewing tobacco Being very ill, such as being on a breathing

machine Having radiation treatments A rare condition called Zollinger

-Ellison syndrome causes stomach and duodenal ulcers. Persons with this disease have a tumor in the pancreas. This tumor releases high levels of a hormone that increases stomach acid.

11

12

Treatment Treatment involves a combination of medications to kill

the H. pylori bacteria (if present), and reduce acid levels in the stomach.

This strategy allows your ulcer to heal and reduces the chance of a relapse

If one has a peptic ulcer with an H. pylori infection, the standard treatment uses different combinations of the following medications for 5 - 14 days:

Two different antibiotics to kill H. pylori, such as clarithromycin (Biaxin), amoxicillin, tetracycline, or metronidazole (Flagyl)

Proton pump inhibitors such as omeprazole (Prilosec), lansoprazole (Prevacid), or esomeprazole (Nexium)

Bismuth (the main ingredient in Pepto-Bismol) may be added to help kill the bacteria

13

Treatment If one has an ulcer without an H.

pylori infection, or one that is caused by taking aspirin or NSAIDs, the doctor will likely prescribe a proton pump inhibitor for 8 weeks

Other medications that may be used for ulcer symptoms or disease are:

• Misoprostol, a drug that may help prevent ulcers in people who take NSAIDs on a regular basis

• Medications that protect the tissue lining (such as sucralfate)

Anti ulcer drugs- Classification

14

Gastric Acid Secretion Inhibitors(a) H2 Antihistaminics- Ranitidine, Famotidine(b) Proton Pump Inhibitors- Omeprazole,

Lansoprazole, Pantoprazole(c) Anticholinergics- Pirenzepine(d) Prostaglandin Analogues- Misoprostal

Gastric neutralizers (Antacids)(a) Systemic- Sodium Bicarbonate(b) Non- Systemic-Mag. Hydroxide, Al.

Hydroxide

15

Anti ulcer drugs- Classification Ulcer Protectives- Sucralfate, Colloidal

Bismuth Subcitrate

Anti H. Pylori drugs- Amoxicillin, Metronidazole, Tetracycline

16

17

Gastro esophageal reflux disease (GERD)

18

Definition and Introduction It is chronic disease occurs due to mucosal

damage caused by reflux stomach acid coming up from the stomach into the esophagus

Gastroesophageal reflux disease, or GERD, is a digestive disorder that affects the lower esophageal sphincter (LES), the ring of muscle between the esophagus and stomach

Doctors believe that some people suffer from GERD due to a condition called  hiatal hernia

19

Pathophysiology GERD is caused by a failure of the cardia

(part of the stomach attached to esophagus)

In healthy patients, the "Angle of His"—the angle at which the esophagus enters the stomach — creates a valve that prevents duodenal bile, enzymes, and stomach acid from traveling back into the esophagus where they can cause burning and inflammation of sensitive esophageal tissue

20

Signs And Symptoms Heartburn Regurgitation (expulsion of food particles from

mouth) Trouble swallowing (dysphagia) Pain with swallowing (odynophagia) Excessive salivation Nausea Chest pain Dyspepsia Barret’s Esophagus

21

Most Probable Causes GERD is caused by a failure of the lower esophageal

sphincter. In healthy patients, the "Angle of His"—the angle at which the esophagus enters the stomach—creates a valve that prevents duodenal bile, enzymes, and stomach acid from traveling back into the esophagus where they can cause burning and inflammation of sensitive esophageal tissue

GERD has been linked to a variety of respiratory and laryngeal complaints such as laryngitis, chronic cough, pulmonary fibrosis, earache and asthma, even when not clinically apparent. These atypical manifestations of GERD is commonly referred to as laryngopharyngeal reflux or as extraesophageal reflux disease (EERD)

22

Most Probable Causes Factors that can contribute to GERD: Hiatal hernia, which increases the likelihood of GERD

due to mechanical and motility factors

Obesity: increasing body mass index is associated with more severe GERD. In a large series of 2000 patients with symptomatic reflux disease, it has been shown that 13% of changes in esophageal acid exposure is attributable to changes in body mass index

Zollinger-Ellison syndrome, which can be present with increased gastric acidity due to gastrin production

23

Most Probable Causes Hypercalcemia, which can

increase gastrin production, leading to increased acidity

Scleroderma and systemic sclerosis, which can feature esophageal dysmotility

Visceroptosis or Glénard syndrome, in which the stomach has sunk in the abdomen upsetting the motility and acid secretion of the stomach

The use of medicines such as prednisolone

24

Prevention Relief is often found by; Raising the head off the bed Raising the upper body with pillows Sleeping sitting up• Eating a big meal causes excess stomach acid

production, and attacks can be minimized by eating small frequent meals instead of large meals, especially for dinner.

• To minimize attacks, a sufferer may benefit from avoiding foods that may trigger their symptoms such as restricting the acidic fruit or juice, fatty foods, coffee, tea, chocolate, or highly spiced foods, especially shortly before bedtime

25

26

Treatment

27

28

Drug therapy- Inhibitors or Neutralizers of gastric acid

secretion(a) Proton Pump Inhibitors- Omeprazole,

Pantoprazole(b) H2 Blockers- Ranitidine, Famotidine(c) Antacids- Mg. Hydroxide, Al. Hydroxide

Barrier Agent- Sodium Alginate

Prokinetic Drugs (Enhance LES tone and promote Gastric Emptying )- Cisapride, Mosapride

29

References http://www.nlm.nih.gov/medlineplus/ency/

article/000206.htm http://www.webmd.com/digestive-disorders/

digestive-diseases-peptic-ulcer-disease https://www.clinicalkey.com/topics/

gastroenterology/peptic-ulcer-disease.html http://www.webmd.com/heartburn-gerd/

guide/reflux-disease-gerd-1  K D Tripathi, Pharmacological Classification of

Drugs, 4th edition.