During this 20-25 minute pre-recorded lecture, Dr. Anthony Weiss discusses the topic of peptic ulcer disease. This in-depth review will provide an update on this for your clinical practice as well as supplement your learning for the ABIM Gastroenterology and Hepatology boards. CME pre-requiste of live Q & A webinar, 8th Annual Mount Sinai Intensive Board Review in Gastroenterology & Hepatology on Sept 22 Mhm. So although the vast majority of ulcers are caused by either nuns to royal use rich by lori. It's important to be aware of the other possible causes of peptic ulcer disease. These include non H. Pylori infections such as C. N. B. H. H. S. V. T. V. Or syphilis. Other drugs besides N. Says can cause ulcers because they're directly caustic such as bisphosphonates and potassium pills. Steroids are listed as a cause of ulcers although they've been shown by themselves not to be a risk factor for ulcers. Uh Unless you're also concurrently using Nsaids, certain hormonal hyper signatory states can cause increased acid production such as Z. Causing excessive gas trin or excess histamine associated with nasty nasty psychosis or milo proliferated disorders with zoophilia in the post surgical setting we have an ass demotic ulcers which are usually caused by poor vascular supply uh the gastric bypass patients. Uh There's an interesting although not fully proven association with H pylori contributing to that other infiltrating diseases such as sarcoidosis. Crohn's. And of course in our patient I see us stress ulcers by far which the biggest risk factors are for peace Are being on prolonged mechanical ventilation or having a waggle apathy. So just emphasis stress ulcers. The major risk factors by far are being on a ventilator for more than 48 hours or having a waggle apathy. Although it's interesting to note on the recent DdC set exam, they did differentiate between having a waggle apathy and being on an anticoagulants which they did not consider risk factor for stress ulcers. These other risk factors here sepsis renal failure. Other systemic illness are really considered contributory but not major risk factors. And of course it's important to remember that central feeding and being on a either P. P. I. Or H. Two prophylaxis is protected against these types of ulcers. Question five. All of the following can increase gastric levels except a proton pump inhibitors be gastric distension. See stimulation of the cells D. H. Pylori, E. Retained Antrim. And the answer here is c stimulation of the cells mm hmm. So this is just a basic type of review question you're likely to see on the boards and this is your basic cheat sheet diagram of acid regulation. Of course we all know that the cells produced Semana Staten which decrease not increase gastric production. One of the pearls here is remember that the gasoline which is produced by the G cell exerts most of its effect indirectly through histamine stimulation by the EC. L. Type cell rather than directly acting on the parietal cell Gaston receptor. When looking at issues of elevated gastric in the board. Questions often likely to differentiate between those with excess acid production and a low ph and those were gas and levels are elevated in response to low acid production and an elevated ph. Examples of the former include Zollinger Ellison syndrome. Examples of the latter include chronic hypertrophic gastritis, pro jump up at their therapy, Other antacid therapy and the economies. Question six. A 72 year old man with Osteoarthritis is having severe symptoms, which is limiting his ability to play tennis. His internist wants to start him on an end, said he's concerned as he remembers being diagnosed with an ulcer in his twenties. His current medications include 81 mg daily of aspirin, 20 mg of FLUoxetine and 10 mg a day of Cinda Staten. So what's your recommendation regarding? Also prevention? Would you give them a cox two specific inhibitors such as celecoxib. Would you put them on promoted in daily nippers all daily? Maybe give him super fate one g twice a day. Or maybe you didn't do nothing. Maybe he's not at risk for peptic ulcer disease. And the answer here is c yes, he is an elevated risk for peptic ulcer disease and he should be on a daily pprd. Mhm. Of course. After h pylori and sides of the other major chorus of peptic ulcer disease. Um there's probably over 10 million people in this country. We take insets on a regular basis and the rate of symptomatic ulcers is quite high as high as 4.5%. Uh serious complications can occur as many uh in 1 to 1.5% over time. And that can account for up to as many as 10,000 deaths per year. Yet only 20 to 25% of people who should be on pp I prophylaxis are actually taking them. Risk factors of course, having had a complicated also one that was perforated bleeding but you at very high risk for another one. Being on multiple insets high dose insets concurrent use of anticoagulants history. The simple ulcer or an uncomplicated ulcer. Being older. Having an H. Pylori infection and being on a steroid. All put you at higher risk for peptic ulcer disease even than sense. And guidelines have clearly been established for who should actually be on PP. I. Prophylaxis. So our patient here, he's over 65. He has a history of an ulcer in the past. He's going to be taking aspirin in addition to the answer that his doctor wants to put them on. So he has more than two risk factors. So he is considered high risk for peptic ulcer disease and should be on A P. P. I. So what works in preventing ulcers and people that need to be on a daily and set? Well the evidence is very strong that pp high profile actress who reduce the incidents and complications of peptic ulcer disease. If they have aged pylori, it should be looked for eliminated music process. Still. Uh we don't use that much because of its dozing in side effect profile but it does have appeared to have some benefit and preventing peptic ulcer disease. One of the keys to this question is to recognize it being on a cox two inhibitor which is less toxic to the stomach. Uh the effect is modest. You have to be careful and patient f cardiovascular risk factors And also key to this patient. He's already taken aspirin. There doesn't appear to be any benefit of them being on a Cox two inhibitor. He still puts it at high risk for peptic ulcer disease. Mhm. H two blockers uh will work but the data tends to suggest you have to be on a higher dose than was recommended for our patient. And the kicker here to remember is that super fate has been not been shown to prevent inset induced ulcers. Yes. Question seven. Testing and treatment for H. Pylori should be done in all cases below, except a first degree relatives of patients of malt lymphoma. B patients with previously resected gastric cancer. See patients with a history of a complicated ulcer but already on the Bp the young adults of abdominal pain but no alarm symptoms or e patients undergoing gastric bypass surgery. And the answer here is a there's no evidence to suggest that people who are first degree relatives of individuals with malt lymphoma need to be tested and treated for H. Pylori. There does not appear to be a familiar risk to this. Mhm. So who should be treated for H Pylori. The list of potential candidates seems to be expanding every year. Clearly, people with active peptic ulcer disease or history of peptic ulcer disease. And H. Pylori should be treated Of course. People with malt lymphoma should be treated as many as 90% of patients who have malt lymphoma will resolve with treatment of H. Pylori. If it's present. Studies from Japan showed that people who have had an endoscopic resection of gastric cancer who do not have the H pylori eradicated are elevated risk of having meticulous lesion. So those people should clearly be treated. Uh The data for uninvestigated dyspepsia or non also dyspepsia is recommended by most guidelines. Um The data is not overwhelming but comes out pretty much more in favor of treating versus not treatment. And it's in it's in our dyspepsia guidelines. And of course as we just talked about people who are chronic user events it's we have H. Pylori should be treated. Other indications retreating H. Pylori which are not universally accepted but are finding support. And most of the guidelines we have these days are people who take low dose aspirin. People with unexplained iron deficiency anemia or B. 12 deficiency. And this is predicated on the concept that people with H. Pylori mame al absorb these nutrients due to a clot jadriyah. Recent data is showing actually the first degree relatives of people with gastric cancer benefit from treating H pylori. It's also been suggested that people from high risk areas for gastric cancer should be treated as well. There's also data support that people with I. T. P the empathic through on both sides. Penick purpura will resolve if you treat H. Pylori in a certain percentage of them. Uh And people undergoing gastric bypass? We're always asked to do endoscopy on pre bariatric surgery patients and assess rage by law. This is based on data showing that it may be associated with increased risk for marginal ulcers. Although the data is not robust, most people accept this as a indication for treatment. This slide summarizes data from a recently published randomized controlled trial in the new England Journal of Medicine last year. Looking at first three relatives of individuals with gastric cancer in this study, just under 1700 people were randomized with about nine years of follow up and the take home messages here and those people who had successful eradication eight. The instance of gastric cancer was about 0.8%. And those people over the same period of time who had a persistent H. Pylori infection. Just about 3% of people had gastric cancer. So a significant reduction in the number of patients who actually developed gastric cancer. Pretty robust findings. Question Eight a 24 year old woman with postprandial epic gastric pain was placed on a mid brazil 20 mg daily. Although she initially responded she's now complaining of bloating. Also she's having multiple loose balboa Miss Daly. You order a serum gastric level which comes back 380 picograms per ml normal is less than 1 10. What's your next step? Do you order a serum chroma gone in A. Level B. You don't worry about it. See the order not treated scan D. Would you stop the P. P. I. Or E. Would you order a secret and stimulation test? And of course the answer here is of course you would stop the PPS. So side effects and potential risks associated with PP. I. Use could easily be the topic of his lecture. Of course mild to moderate elevations and gastric are common and bloating abdominal discomfort and diarrhea are the most common side effects. Seeing the PPS and those symptoms in themselves should not necessarily be a cause for concern over the years. However numerous reports have been made about potential issues. As you see here they've been ft warnings about potential interactions with quadrangle risk, increased risk of fractures. Osteoporosis related. Um There are some concerns though it's rare about hippo magna xenia and there's a slight increased risk with C. Diff. Um There's been a lot of other potential bad outcomes associated with chronic PP. I. Use. Although upon closer review many of these uh issues seem to be greatly overstated. That's interesting. In 2017 the A. D. A. Issued a clinical practice update on this issue pointing out that many of these published concerns were based on low quality observational data which suffered from significant confounding uh of interest here was the observational data suggesting an increased risk of myocardial infarction. However when you looked at results of a randomized controlled trial? Uh There was no association noted. And if this slide shows that even if these findings were reliable, the absolute effect size would be very very small. And so the position paper concluded that clearly uh certain patients do benefit and need to be on maintenance PP. I. Therapy people with a roast of esophagitis, barrettes and patients are on and said these are all people that need to be on maintenance therapy and clearly benefit from it. Most of the evidence of adverse events associated with PP. I use suffer from significant method method, a logical bias and the possible magnitude these effects are quite small. They came out actually saying that routine monitoring of bone density in the use of calcium and vitamin supplements is not recommended based just on PP. I use of course it's a general it's always good to use look to use the lowest possible dose uh of any medication including PPS. Mhm, mm hmm. And that's all I have for now. I'm gonna conclude this talk. I hope you found this information useful. Look forward to any questions you might have in our virtual meeting later on.