Introduction

Peptic ulcer disease (PUD) refers to an ulceration that forms on the muscular mucosa in the wall of the Gl tract. The most common types of PUD are duodenal ulcers (DU) and gastric ulcers (GU). GU are usually located in the antrum or lesser curvature of the stomach. PUD is common and may adversely affect quality of life unless properly diagnosed and treated. The high prevalence and relapse rate associated with PUD pose a substantial economic burden. Peptic ulcers are most commonly caused by one ofthree etiologies: (a) Helicobacter pylori infection; (b) use of nonsteroidal anti-inflammatory drugs (NSAIDs); or (c) stress-related mucosal damage (SRMD). A number of pathophysiologic variables can be used to distinguish these three common types of peptic ulcer (Table 18-1). This chapter will focus on strategies to optimize pharmacotherapy for patients with PUD related to H. pylori or NSAID therapy.

Table 18-1 Characteristics of Common Causes of PUD

H, pyiori

hiAID

SRMD

Cuse!

Outwit

Cf«xik

Acute

Pniraiy location of da™ge

Ojodeoum

Stomach

Storruch

Pn?i(we oif ^yinfjiom;

frequent

tore

fare

RiinuiynctHwnisfii far

infection iC5ulluiy in rtljmiiWUxy state

Loss of dcfcnsi' inocfw nismc

LtKi of dtfimc mechonBrtS

dcnUon

L>.'[Hti(jf ulitil

He Ljl

Dctff}

SuOfl'kijI

Dependence on acid To«

Greater

Lesser

Lesser

l!«Ji]Q5jl(Ji)IIVKJC

tharac terisilion of (Til

Minor

Major

Major

ijtMtPng

Responsive to acid

No

Yes

Ihtfjfiy

NSAII). lYHiMiKjiil.t:.HN[i-illfl.ilrVri.HLiiy iIiiiii: f'l.'l). ih'iiIk ufcii clniuw<: SUM i), ilrnis-iddWl finyijs.il iLim:^'

NSAII). lYHiMiKjiil.t:.HN[i-illfl.ilrVri.HLiiy iIiiiii: f'l.'l). ih'iiIk ufcii clniuw<: SUM i), ilrnis-iddWl finyijs.il iLim:^'

SRMD occurs most frequently in critically ill patients and is thought to be caused by factors such as compromised mesenteric perfusion rather than H. pylori or NSAIDs. Its onset is usually acute, and in a small proportion of patients may progress to deep ulceration and hemorrhage.

Less common causes of peptic ulceration include Zollinger-Ellison syndrome (ZES), cancer chemotherapy, radiation, and vascular insufficiency. ZES is caused by a gastrin-producing tumor called a gastrinoma and results in gastric acid hypersecretion. High-dose oral proton pump inhibitor (PPI) therapy is the initial treatment of choice for ZES; intermittent IV PPI therapy may be required for any patient in whom oral therapy is contraindicated.1

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