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home - Stomach - Peptic Ulcer Disease - Management Of Refractory Ulcers Written by Dr Sebastian Zeki

Knows the range of organic and non-organic causes of dyspepsia. Be
aware of current BSG and NICE guidelines for selecting patients for
investigation. Know the significance of alarm symptoms
Understands the relevance of Helicobacter pylori infection and how it
can be detected and treated.
Recognise the adverse effect of nonsteroidal anti-inflammatory drugs
Understands the physiology of gastric acid secretion, mucosal
protection and gastroduodenal motility and know how drugs can
modify these
Knows the complications of ulcer disease, the principles of surgery
that may be required and be aware of post-operative sequelae

Makes a thorough clinical assessment, perform appropriate
investigations and be familiar with how medical treatments are used.
Show awareness of how to recognise and manage complications

Can explain the steps taken towards making a diagnosis and
planning treatment clearly and comprehensibly


Knows the causes of upper gastrointestinal bleeding and its
Understands the circulatory disturbance associated with blood loss
and the pathophysiology underlying the clinical manifestations of
hypovolaemic shock
Knows the principles of assessing hypovolaemia and of restoring the
circulation. Be able to identify and correct coagulopathy
Knows the principles of using the various risk stratification tools SCE 1
Knows how endoscopic techniques are used to control bleeding CbD, DOPS, SCE 1
Understands how oesophageal and gastric varices develop and the
endoscopic and pharmacological methods that are used to control
blood loss

Can make an accurate clinical assessment, and stratify the risk. Know
the principles of fluid resuscitation and arrange endoscopy
Is aware of methods to secure haemostasis, recognise signs of rebleeding and liaise with other disciplines (such as interventional
radiology or surgery

Assesses and treats patients who have bleeding with appropriate
degree of urgency.


Understands why part or all of the patient’s stomach is removed and
the altered post-surgical anatomy

Understands the problems of a gastro-enterostomy and a Roux-en-y

Has awareness of dumping syndromes
Knows the various surgical operations performed for obesity (bariatric
surgery) and their complications

Can give nutritional advice and choose the appropriate method by
which an enteral feeding tube is inserted into the small bowel

Can initiate the use of pancreatic enzyme therapy
Has ability to recognise and treat early and late dumping syndrome
Able to help the patient carers friends and family understand how
the patient can be encouraged to gain weight

Works closely with dieticians and surgical colleagues

Management Of Refractory Ulcers

Diagnostic Approach-Exclude H.pylori (use more than 1 test) and biopsy everything.-Fasting serum gastrin should be measured to exclude gastrinoma and antral G cell hyperfunction but caution is necessary because both PPI and H. pylori can raise gastrin levels.-Plasma salicylate levels. Refractory or recurrent peptic ulcer disease Refractory Ulcers — (= No healing after >8weeks treatment)25 % of refractory ulcers are asymptomatic. TreatmentPPIs heal ulcers > H2-receptor antagonists. (85% vs 75% at 4 weeks).Healing of the DU is likely to occur if the gastric pH > 4 for 90 % of the day (stops pepsin from working and being generated).If cause has been removed, but refractory ulcer, continue PPI.No evidence for PPI + H2 antags.Surgery may be necessary. Conditions underlying refractory and recurrent ulcers.Persistent H. pylori infection can contributeNSAIDs account for 40% — 44% discovered by measuring platelet cyclooxygenase activity; salicylate levels should be measured.Large ulcers — Large and small PUD heal at the same rate on antacids, approximately 3 mm per week.Ulcer healing was less likely in ulcers ≥10 mm in diameter.Big ulcers also are often densely scarred.Smoking contributes to impaired healing but may not be a risk factor once H. pylori is eradicated.Acid hypersecretory states can occasionally due to gastrinoma.In nongastrinoma refractory DU, increased basal, nocturnal, and maximal acid secretion may be a contributing factor in a subset of patients.Atrophic gastric predicts enhanced healing, an effect presumably due to lower levels of acid secretion.Impaired response to antisecretory agents can occur.H2 receptor antagonists tolerance can develop.Poor response to PPI is probably P450 mediated rapid metabolism.Comorbid diseases may promote ulcer formation and complications and impair healing. Factors influencing recurrence:The quality of duodenal ulcer healing- this reflects the degree of restoration of normal epithelial architecture.Marked inflammation.An absence of glandular structure.Blunt or absent villi- markers of poor histologic restoration.Duodenal bulb deformity-presumably due to dense scarring, and gastric metaplasia in the duodenum have also predicted DU recurrence.A prior history of ulcer complications-predicts complicated recurrence.A history of prior frequent recurrences or ulcers refractory to initial therapy. Prevention and treatment — Maintenance therapy is indicated to prevent recurrence in high-risk subgroups, defined by a history of complications, frequent recurrences, or refractory, giant, or severely fibrosed ulcers.Recurrences on maintenance therapyAsymptomatic recurrences account for 25 to 40 % of recurrences on therapy for both DU and GU.Ulcers that occur on maintenance therapy are more likely to be asympto-matic. Written by Dr Sebastian Zeki

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