Medical Therapy

H2 receptor antagonists competitively bind histamine receptors on the surface of the gastric parietal cell. Several different H2 blockers are clinically available. However, there is no significant difference among these different H2 blockers in regards to their efficacy in healing ulcers. About 70% of patients are ulcer-free after 4 weeks of treatment. Up to 90% of patients will be ulcer-free at the end of 8 weeks of treatment.

Proton pump inhibitors bind to membrane-bound H+/K+/ATPase on parietal cells and in doing so block the intraluminal secretion of hydrogen ion. Direct comparisons between omeprazole and H2 blockers have demonstrated that omeprazole is superior in regards to pain relief and ulcer healing. About 80% of patients are ulcer-free after 2 weeks of treatment. Up to 95% are ulcer-free at the end of 4 weeks of treatment.

Sucralfate is activated at a pH of <3.5 and polymerizes to form an insoluble gel which binds to proteins on injured mucosa. In doing so it forms a barrier between injured mucosa and luminal acid to prevent further acid-induced injury. Sucralfate also binds free bile salts and pepsin, reducing their ability to cause mucosal damage. Additionally, it stimulates mucosal production of mucus, bicarbonate, and prostag-landins. As it does not influence acid secretion, sucralfate does not promote bacterial overgrowth within the stomach. Acid-reducing therapy with proton pump inhibitors or H2 receptor antagonists raise intraluminal gastric pH and consequently decrease the efficacy of sucralfate when these medications are used in combination. Sucralfate displays ulcer-healing efficacy similar to that of H2 blockers.

Antacids work by neutralizing gastric acid. They have ulcer-healing efficacy comparable to H2 blockers. However, effective treatment with antacids requires frequent daily dosing which negatively influences patient compliance.

The antimicrobial treatment of Helicobacter pylori is an important component of the treatment of peptic ulceration. As previously mentioned, H. pylori is associated

with duodenal ulceration in nearly 100% of cases and with gastric ulceration in about 60% of cases. Helicobacter infection should be considered when patients experience ulcer recurrence on maintenance medical therapy or when peptic ulcers fail to heal. Multiple medical regimens exist consisting of some combination of clarithromycin, metronidazole, bismuth, and/or tetracycline. Triple therapy is becoming more popular with use of a PPI and two antibiotics (i.e., omeprazole, clarithromycin and metrinidazole). Regardless of the exact regimen used, a 10-14 day course leads to eradication of H. pylori in approximately 90% of cases.

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