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Experts recommend treating the patient with antibiotics to eradicate H. pylori. The patient taking NSAIDs may take a prostaglandin analog (misoprostol) to suppress ulceration (or the patient may take the analog with NSAIDs to prevent ulceration). Histamine-2 (H2) receptor antagonists or proton pump inhibitors may reduce acid secretion. A coating agent or bismuth may be administered to the patient with a duodenal ulcer to protect the lining.
If GI bleeding occurs, emergency treatment begins with passage of a nasogastric (NG) tube to allow for iced saline lavage, possibly containing norepinephrine. Gastroscopy allows visualization of the bleeding site and coagulation by laser or cautery to control bleeding. This type of therapy allows postponement of surgery until the patient’s condition stabilizes. Surgery is indicated for perforation, unresponsiveness to conservative treatment, and suspected malignancy. Surgery for peptic ulcers may include:
❑ vagotomy and pyloroplasty: severing one or more branches of the vagus nerve to reduce hydrochloric acid secretion and refashioning the pylorus to create a larger lumen and facilitate gastric emptying
❑ distal subtotal gastrectomy (with or without vagotomy): excising the antrum of the stomach, thereby removing the hormonal stimulus of the parietal cells, followed by anastomosis of the rest of the stomach to the duodenum or the jejunum
❑ pyloroplasty: surgical enlargement of the pylorus to provide drainage of gastric secretions.
Source: Professional Guide to Diseases (Eighth Edition), 2005
H. pylori can be treated with a combination of agents and eradicated with antibiotics. Pharmacologic treatments include antisecretory agents, such as proton pump inhibitors and histamine-2 (H2)-receptor antagonists. Proton pump inhibitors work by binding to hydrogen-potassium adenosine triphosphatase, located at the surface of gastric parital cells to block formation of gastic acid. H2-receptor antagonists inhibit histamine binding to H2 receptors on the gastric parietal cell, which in turn decreases acid secretion. Drug therapy, which protects the mucosa, includes prostaglandin analogs and antacids. Prostaglandin analogs may be given to patients taking NSAIDs to suppress ulceration.
GI bleeding may be treated by giving H2-receptor antagonists I.V. as a continuous infusion. Upper endoscopy is preferred as a diagnostic tool when GI bleeding is present because an injection of epinephrine or saline (to surround the ulcer) can be performed to stop the bleeding during the procedure; cautery may also be used for hemostasis.
Surgery is indicated for perforation of the ulcer, continued bleeding despite medical treatment, and suspected malignancy. Surgical procedures for peptic ulcers and gastric outlet obstruction include:
❑ vagotomy and pyloroplasty: severing one or more branches of the vagus nerve to reduce hydrochloric acid secretion and refashioning the pylorus to create a larger lumen and facilitate gastric emptying
❑ distal subtotal gastrectomy (with or without vagotomy): excising the antrum of the stomach, thereby removing the hormonal stimulus of the parietal cells, followed by anastomosis of the remainder of the stomach to the duodenum or the jejunum.
Source: Handbook of Diseases, 2003
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