Management of peptic ulcer disease

HP eradication is the cornerstone of modern therapy for peptic ulcers, as this will successfully prevent relapse and eliminate the need for long-term therapy in the majority of patients. All patients with proven acute or chronic duodenal ulcer disease, and those with gastric ulcers who are HP-positive, should be offered eradication therapy as first-line treatment. Treatment is based upon a proton pump inhibitor taken simultaneously with two antibiotics for a period of seven days. Compliance, side-effects and metronidazole resistance influence the success of therapy.

Nurses involved in the care of patients with peptic ulcer disease may include behavioural modification techniques by incorporating the following recommendations:

• NSAIDs should be avoided.

• Alcohol should be taken in moderation.

• No specific dietary advice is required.

At present, the most frequently used medical treatment for the suppression of gastric acid secretion in peptic ulcer disease is the administration of proton pump inhibitors. These inhibitors are effective in decreasing gastric acid by inhibiting the enzyme responsible for the final step of acid secretion, hydrogen-potassium adenosinetriphosphatase (ATPase) in the parietal cell membrane. After a few days of treatment, virtual achlorhydria is achieved and rapid healing of both gastric and duodenal ulcers follows. Omeprazole and lansoprazole are important components of HP eradication regimens. Proton pump inhibitors are also much more effective than H2 antagonists for the healing and maintenance of reflux oesophagitis.

Other drugs available for the short-term management of peptic ulcer symptoms and other dyspeptic disorders include antacids and histamine H2 receptor antagonists. These can be purchased without prescription in the UK.

Antacids act to neutralise gastric acid and strengthen the gastric mucosal barrier. They are widely available for self-medication and are used for relief of minor dyspeptic symptoms. Calcium compounds cause constipation, while magnesium-containing agents cause diarrhoea.

Reduction of acid secretion in peptic ulcer disease can be effected by antagonising the action of histamine. Using histamine H2 receptor antagonists, symptoms remit promptly, usually within days of starting treatment, and 80% of duodenal ulcers will heal after four weeks. These drugs do not inhibit acid secretion to the same degree as the proton pump inhibitors but are useful for the short-term management of reflux oesophagitis.

The effectiveness of diet manipulation in ulcer healing is unknown. Foods known to increase acid secretion include milk, alcohol and coffee.

Surgical management of peptic ulcer disease

Surgery was once the definitive treatment for peptic ulcer disease. However, the development of effective acid-suppressing drugs has made elective surgery for peptic ulcer disease a rare event. Emergency gastric surgery is indicated for patients who do not adhere to medical therapy, and for peptic ulcers which are refractive to medical therapy, or in extreme circumstances of uncontrolled haemorrhage from a gastric ulcer. Three surgical procedures are indicated for the treatment of peptic ulcer disease: partial gastrectomy with gastroduodenostomy, partial gastrectomy with gastrojejunostomy, and highly selective vagotomy.

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