TOPIC= PEPTIC ULCER

SUBMITTED TO SYED NASIR ASGHAR

Peptic ulcer Definition of ulcer:

A lesion of the skin or a mucous membrane such as the one lining the stomach or duodenum that is accompanied by formation of pus and necrosis of surrounding tissue, usually resulting from inflammation or ischemia.

Ulcer: An area of tissue erosion, for example, of the skin or lining of the gastrointestinal (GI) tract. Due to the erosion, an ulcer is concave. It is always depressed below the level of the surrounding tissue. Ulcers can have diverse causes. Ulcers on the skin are often due to irritation, as with bedsores, and they may become infected and inflamed as they grow. Ulcers in the GI tract were once attributed to stress but most are now believed to be due to infection with the bacteria H. pyloridus. GI ulcers, however, may be made worse by stress, smoking and other noninfectious factors. The word "ulcer" traveled across the English Channel from the French "ulcere" which, in turn, came from the Latin "ulcus, ulceris" meaning "sore, sore spot, painful spot, or ulcer."

1-Definition :
A peptic ulcer, also known as PUD or peptic ulcer disease, is an ulcer (defined as mucosal erosions equal to or greater than 0.5 cm) of an area of the gastrointestinal tract that is usually acidic and thus extremely painful. Peptic ulcers are open sores that develop on the inside lining of your esophagus, stomach and the upper portion of your small intestine. The most common symptom of a peptic ulcer is abdominal pain. Peptic ulcers that occur on the inside of the stomach are called gastric ulcers. Peptic ulcers that occur inside the hollow tube (esophagus) where food travels from your throat to your stomach are called esophageal ulcers. Peptic ulcers that affect the inside of the upper portion of your small intestine (duodenum) are called duodenal ulcers.

& a peptic ulcer is an area of damage to the lining of either the stomach or the wall of the small bowel. & Ulcers are defined as a breach in the mucosa of the alimentary tract, which extends through the muscularis mucosa into the sub mucosa or deeper. (Erosion differs from an ulcer in being partial thickness mucosal defect). & Peptic ulcers are chronic most often solitary, lesions that occur in any portion of gastrointestinal tract exposed to the aggressive action of acid-peptic juices.

Causes:
Eenvironmental and hereditary factors influence common medical diseases including peptic ulcer although Helicobacter pylori and non-steroidal antiinflammatory drugs (NSAID) use are main aetiological factors for peptic ulcer (liu et al, 2009.

1. Helicobacter pylori
It is a helical (spiral) shaped microaerophilic gramnegative bacillus. It has four to six sheathed flagella. The organism is slowly growing in vitro and grows on blood agar and selective blood agar medium (Skirrows) (Malaty, 2007). The organism produces
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urease and mucolytic proteases that are important for its survival and pathogenic effect. The organisms virulence factors needed for colonization includes motility, adhesins, proteases, phospholipases, cytokines, cytotoxins and urease. Urease most likely protects the organism from the acidic environment (Sedlack and Viggiano, 2008).

2. NSAID (Non-steroidal anti-inflammatory drugs)

NSAID use is a common cause of peptic ulcer disease. Within 14 days after the start of such treatment, about 5% of patients develop gastric mucosal erosions or ulcers. If usage continues for 4 weeks or longer, this proportion increases to 10%. The risk of developing ulcer with NASID use is higher in older patients, patients with a previous history of ulcer and in patients who use corticosteroids (Kuipers and Blaser, 2007).

3. Environmental factors (smoking, stress and diet)

Duggan and Duggan (2006) suggested a link between smoking and peptic ulcer disease. About diet, they perceived little evidence in the literature correlating alcohol, caffeine and fibre intake to peptic ulcer disease. They suggested high sugar intake correlates to duodenal ulcer, while high salt intake links to increased gastric ulcer risk. Stress influences duodenal ulcers more than gastric ulcer (Szabo et al, 2007).

4. Genetic considerations
Duggan and Duggan (2007) suggested that 39% to 62% of susceptibility to peptic ulcer disease is explainable on hereditary basis. They suggested heredity is determining to the acquisition of Helicobacter pylori, with no link

between genetic factors responsible for developing peptic ulcer and those responsible for Helicobacter acquisition Peptic ulcers occur when acid in the digestive tract eats away at the inner surface of the esophagus, stomach or small intestine. The acid can create a painful open sore that may bleed. Digestive tract is coated with a mucous layer that normally protects against acid. But if the amount of acid is increased or the amount of mucus is decreased, you could develop an ulcer. Causes include:
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A bacterium. A common cause of ulcers is the

corkscrew-shaped bacterium Helicobacter pylori. H. pylori bacteria commonly live and multiply within the mucous layer that covers and protects tissues that line the stomach and small intestine. Often, H. pylori causes no problems. But sometimes it can disrupt the mucous layer and inflame the lining of your stomach or duodenum, producing an ulcer. It's not clear how H. pylori spreads. It may be transmitted from person to person by close contact, such as kissing. People may also contract H. pylori through food and water.

Regular use of pain relievers. Certain over-the-counter and prescription pain medications can irritate or inflame the lining of your stomach and small intestine. These medications include aspirin, ibuprofen (Advil, Motrin, others), naproxen (Aleve, Anaprox, others), ketoprofen and others. Peptic ulcers are more common in older adults who take pain medications frequently, such as might be common in people with osteoarthritis. To help avoid digestive upset, take pain relievers with meals. If you have been diagnosed with an ulcer, make sure your doctor knows this when prescribing any pain
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reliever. The pain reliever acetaminophen (Tylenol, others) doesn't cause peptic ulcers.
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Other medications. Other prescription medications that can also lead to ulcers include medications used to treat osteoporosis called bisphosphonates (Actonel, Fosamax, others). The lining of the stomach is usually protected from the damaging effects of stomach acid. When that protection fails, an ulcer forms. There are a few different ways this happens.
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Helicobacter pylori (H. pylori) -- H. pylori, a type of bacteria, is responsible for most ulcers. This organism weakens the protective coating of the stomach and first part of the intestine and allows damaging digestive juices to eat away at the sensitive lining below. As many as 20% of Americans over age 40 have H. pylori living in their digestive tract, but most do not develop ulcers.

Nonsteroidal anti-inflammatory drugs (NSAIDs) Long-term use of these pain relievers is the second most common cause of ulcers. These drugs block prostaglandins, substances in the stomach that help maintain blood flow and protect the area from injury. Some people are more susceptible to this side
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effect of NSAIDs than others. These drugs include ibuprofen (Advil, Motrin), naproxen (Aleve), and ketoprofen (OrudisKT), as well as prescription drugs. Some may be more likely to produce ulcers than others. If you must use long-term pain medications, talk to your doctor about which ones are safest. Other causes of ulcers are conditions that can result in direct damage to the wall of the stomach or duodenum, such as heavy use of alcohol, radiation therapy, burns, and physical injury. A major causative factor (60% of gastric and up to 90% of duodenal ulcers) is chronic inflammation due to Helicobacter pylori that colonizes the antralmucosa. The immune system is unable to clear the infection, despite the appearance of antibodies. Thus, the bacterium can cause a chronic active gastritis (type B gastritis), resulting in a defect in the regulation of gastrin production by that part of the stomach, and gastrin secretion can either be decreased (most cases) resulting in hypo- or achlorhydria or increased. Gastrin stimulates the production of gastric acid by parietal cells and, in H. pylori colonization responses that increase gastrin, the increase in acid can contribute to the erosion of the mucosa and therefore ulcer formation. Another major cause is the use of NSAIDs The gastric mucosa protects itself from gastric acid with a layer of mucus, the secretion of which is stimulated by certain prostaglandins. NSAIDs block the function of cyclooxygenase 1 (cox-1), which is essential for the production of these prostaglandins. COX-2 selective antiinflammatories (such as celecoxib or the since withdrawn rofecoxib) preferentially inhibit cox-2, which is less essential in the gastric mucosa, and roughly halve
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the risk of NSAID-related gastric ulceration. As the prevalence of H. pylori-caused ulceration declines in the Western world due to increased medical treatment, a greater proportion of ulcers will be due to increasing NSAID use among individuals with pain syndromes as well as the growth of aging populations that develop arthritis. The incidence of duodenal ulcers has dropped significantly during the last 30 years, while the incidence of gastric ulcers has shown a small increase, mainly caused by the widespread use of NSAIDs. The drop in incidence is considered to be a cohort-phenomenon independent of the progress in treatment of the disease. The cohort-phenomenon is probably explained by improved standards of living which has lowered the incidence of H. pylori infections. Although some studies have found correlations between smoking and ulcer formation,[9] others have been more specific in exploring the risks involved and have found that smoking by itself may not be much of a risk factor unless associated with H. pylori infection Some suggested risk factors such as diet, spice consumption and blood type, were hypothesized as ulcerogens (helping cause ulcers) until late in the 20th century, but have been shown to be of relatively minor importance in the development of peptic ulcers. Similarly, while studies have found that alcohol consumption increases risk when associated with H. pylori infection, it does not seem to independently increase risk, and even when coupled with H. pylori infection, the increase is modest in comparison to the primary risk factor.

Gastrinomas (Zollinger Ellison syndrome), rare gastrinsecreting tumors, also cause multiple and difficult to heal ulcers.

Stress
Researchers also continue to look at stress as a possible cause, or at least complication, in the development of ulcers. There is debate as to whether psychological stress can influence the development of peptic ulcers. Burns and head trauma, however, can lead to physiologic stress ulcers, which are reported in many patients who are on mechanical ventilation.

classification
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Stomach (called gastric ulcer) Duodenum (called duodenal ulcer) Oesophagus (called Oesophageal ulcer) Meckels Diverticulum (called Meckels Diverticulum ulcer)

Types of peptic ulcers

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Type I: Ulcer along the lesser curve of stomach Type II: Two ulcers present one gastric, one duodenal Type III: Prepyloric ulcer Type IV: Proximal gastroesophageal ulcer Type V: Anywhere along gastric body, NSAID induced

Assessment
1. Abdominal pain o Occurs in the epigastric area radiating to the back; described as dull, aching, and gnawing. o Pain may increase when the stomach is empty, at night, or approximately 1 to 3 hours after
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eating. Pain is relieved by taking antacids (common with duodenal ulcers). 2. Nausea, anorexia, early satiety (common with gastric ulcers), belching. 3. Dizziness, syncope, hematemesis, melena with GI hemorrhage: o Positive fecal occult blood o Decreased hemoglobin and hematocrit, indicating anemia. o Orthostatic blood pressure and pulse changes. 4. Peptic ulcer disease may be asymptomatic in up to 50% of persons affecte

Differentiating Gastric and Duodenal Ulcers: Gastric Ulcer Duodenal Ulcer

Gnawing epigastric Gnawing epigastric pain pain occurring 30 occurring 2-3 hours after minutes to 1 hour after meals meals Aggravated by eating (because acid secretion increase at meal time) leads to weight loss Relieved by food (because the pyloric sphincter, at the junction of stomach and duodenum, closes upon eating to concentrate food in the stomach) causes weight gain Not relived

Relieved by vomiting (because acid is expelled out) No pain at hours of sleep (HCl production

Pain at hours of sleep (because gastric

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decreases at hours of sleep) More common in persons older than age 50

emptying continuous at hours of sleep) More common between ages 25 and 50

Risk factors:
You may have an increased risk of peptic ulcers if you:
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Smoke. Smoking may increase the risk of peptic ulcers in people who are infected with H. pylori.

Drink alcohol. Alcohol can irritate and erode the mucous lining of your stomach, and it increases the amount of stomach acid that's produced.

Have uncontrolled stress. Although stress alone isn't a cause of peptic ulcers, it's a contributing factor. You may undergo stress for a number of reasons an emotionally disturbing circumstance or event, surgery, or a physical trauma, such as a burn or other severe injury
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y y y

Heredity Older age Chronic pain, from any cause such as arthritis, fibromyalgia, repetitive stress injuries (like carpal tunnel syndrome), or persistent back pain, causing long-term use of aspirin or NSAIDs Alcohol abuse Diabetes may increase your risk of having H. pylori Lifestyle factors, including chronic stress, coffee drinking (even decaf), and smoking, may make you more susceptible to damage from NSAIDs or H. pylori if you are a carrier of this organism. But these factors do not cause an ulcer on their own.

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Signs & symptoms:

Pain is the most common symptom Burning pain is the most common peptic ulcer symptom. The pain is caused by the ulcer and is aggravated by stomach acid coming in contact with the ulcerated area. The pain typically may:
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Be felt anywhere from your navel up to your breastbone Be worse when your stomach is empty Flare at night Often be temporarily relieved by eating certain foods that buffer stomach acid or by taking an acid-reducing medication Disappear and then return for a few days or weeks

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Other signs and symptoms Less often, ulcers may cause severe signs or symptoms such as:
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The vomiting of blood which may appear red or black Dark blood in stools or stools that are black or tarry Nausea or vomiting Unexplained weight loss

Appetite changes
When to see a doctor See your doctor if you have persistent signs and symptoms that worry you. Over-the-counter antacids and acid blockers may relieve the gnawing pain, but the relief is short-lived. If your pain persists, see your doctor.

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Pain may be relieved by antacids or milk Heartburn Indigestion (dyspepsia) Belching abdominal pain, classically epigastric with severity relating to mealtimes, after around 3 hours of taking a meal (duodenal ulcers are classically relieved by food, while gastric ulcers are exacerbated by it); bloating and abdominal fullness; waterbrash (rush of saliva after an episode of regurgitation to dilute the acid in esophagus although this is more associated with GERD); nausea, and copious vomiting; loss of appetite and weight loss; hematemesis (vomiting of blood); this can occur due to bleeding directly from a gastric ulcer, or
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from damage to the esophagus from severe/continuing vomiting. melena (tarry, foul-smelling feces due to oxidized iron from hemoglobin); rarely, an ulcer can lead to a gastric or duodenal perforation, which leads to acute peritonitis. This is extremely painful and requires immediate surgery.

A history of heartburn, gastroesophageal reflux disease (GERD) and use of certain forms of medication can raise the suspicion for peptic ulcer. Medicines associated with peptic ulcer include NSAID (non-steroid antiinflammatory drugs) that inhibit cyclooxygenase, and most glucocorticoids (e.g. dexamethasone and prednisolone).

Clinical investigations:
Tests and diagnosis In order to detect an ulcer, you may have to undergo diagnostic tests, such as:
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Tests for H. pylori. Your doctor may recommend tests to determine whether the bacterium H. pylori is present in your body. Which type of test you undergo depends on your situation. H. pylori may be detected in a blood test, a stool test or a breath test. For the breath test, you drink a small glass of clear, tasteless liquid that contains radioactive carbon. H. pylori breaks down the substance in your stomach. Later, you blow into a bag, which is then sealed. If you're infected with H. pylori, your breath sample will contain the radioactive carbon in the form of carbon dioxide. Using a scope to examine your upper digestive system (endoscopy). During endoscopy, your doctor passes a hollow tube equipped with a lens (endoscope) down your
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throat and into your esophagus, stomach and small intestine. Using the endoscope, your doctor looks for ulcers. If your doctor detects an ulcer, he or she may remove small tissue samples (biopsy) for laboratory examination. A biopsy can also identify the presence of H. pylori in your stomach lining. Your doctor is more likely to recommend endoscopy if you are older, have signs of bleeding, or have experienced recent weight loss or difficulty eating and swallowing.
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X-ray of your upper digestive system. Sometimes called a barium swallow or upper gastrointestinal series, this series of X-rays creates images of your esophagus, stomach and small intestine. During the X-ray, you swallow a white liquid (containing barium) that coats your digestive tract and makes an ulcer more visible. H. pyloritest As H. pylori is the most common cause of a peptic ulcer, your GP may test you for the bacterium and, if necessary, prescribe medicines to treat the infection. H. pylori can be detected in a urea breath test. You will be asked to swallow a liquid containing a substance called urea that is broken down by H. pylori to produce water and carbon dioxide. Your breath will then be tested using a machine for the amount of carbon dioxide in it. If the carbon dioxide is over a certain level, H. pylori is present. Alternatively a sample of your blood or your faeces will be sent to a laboratory to test for H. pylori. Endoscopy If you have a suspected peptic ulcer, your GP may arrange a gastro-intestinal endoscopy (also called a gastroscopy). Not everyone who has abdominal pain needs one, so your GP may use one of the other
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tests first. However, endoscopy is the only way to be certain whether or not you have a peptic ulcer. An endoscopy is a procedure that allows a doctor to look at the inside of your body. The test is done using a narrow, flexible, tube-like telescopic camera called an endoscope that is passed through your mouth and into your stomach. The procedure usually lasts a few minutes. Your doctor will be able to see the lining of your stomach and can take a sample of your stomach lining at the same time. This sample is either sent to a laboratory and examined under a microscope, or directly tested for H. pylo.

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Biopsy is necessary to distinguish between benign and malignant ulcers. Biopsy should be taken from the ulcer edge, at least from each quadrant. Upto 10-12 biopsies may be taken to exclude cancer. Repeat endoscopy may be necessary if biopsies are negative and there is high index of suspicion.

laboratory test
Title &Frequency 1. CBC should be repeated in Once in 10 case of abnormalities revealed days (fortreatmentmonitoring) 2. Blood type 3. Rh-factor 4. Feces for occult blood 5. Urinalysis Once Once Once Once

6. Iron in blood serum Once 7. Reticulocyte count Once 8. Blood sugar Once 9. Histological and cytological Once evaluation of biopsy sample if endoscopy was conducted

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10. Urease test Once* *This test is performed to detect active infection. Its specificity and sensitivity exceed 90%. May be also used to diagnose successful eradication of Helicobacter pylori. Antibiotics and bismuth medications should be discontinued at least four weeks before the test. Ranitidin and other histamine receptors blockers should be discontinued at least seven days prior to the procedure. The test should be conducted no earlier than six hours after the last meal.This test is not recommended in case of the prior partial gastrectomy related to gastric cancer, prolonged use of proton pump inhibitors (Omeprasol, etc.) and severe esophageal reflux and prolonged use of y NSAID irrespective of the fact whether the ulcer has developed or not.

Pathophysiology:
stomach produces acid to help you digest food. The lining of your stomach and first part of your small bowel (duodenum) have a layer of mucus that protects them from the acid. If this protection mechanism doesn't work properly, the acid can eat into your stomach lining and cause an ulcer.

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The different parts of the digestive system Stomach (gastric) ulcers and small bowel (duodenal) ulcers are collectively known as peptic ulcers. Duodenal ulcers are more common. Stomach ulcers usually affect people between the ages of 40 and 80, and duodenal ulcers affect people aged 20 to 60. Peptic ulcers are more common in women than men. The size of peptic ulcers can vary from one millimetre to several centimetres across. They look similar to mouth ulcers.

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III.PATHOPHYSIOLOGY infection by H. pylori caffeine, alcohol stress

stomach produces HCl and an enzyme called pepsin to digest food

when acid and enzyme overcome the defense mechanism of gastrointestinal

erosion of mucosal wall, infection, chronic inflammation

stomach pain, nausea, vomiting, loss of appetite, loss of weight,

cigarette regular intake of Aspirin and nonsteroidal antiinflammatory

severe ulcer may cause

vomiting of blood or dark materials, black in stool

Many diseases are roaming around the environment now a day. Some have evolved from other diseases; some of these evolved from simpler diseases and after they have evolved they have become more dangerous and complicated. One of these diseases is the peptic ulcer. Peptic ulcer or also known as peptic ulcer disease (PUD) is a type of ulcer that occurs in the area of the gastrointestinal tract that is, most of the time acidic hence, it is extremely paiful. There are many classifications of ulcer depending on the region or the area of the body where in it is affected. There is the gastric ulcer which is in the stomach area, the duodenal ulcer which is in the duodenum, the esophageal ulcer found in the esophagus and there is the Meckel's diverticulum ulcer found in the Meckel's diverticulum. The pathophysiology of peptic ulcer describes the causes of ulcer, it's evolution as a disease and ways to prevent it and eventually treat it. First we must know how such disease occurs. Since most of the
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time it occurs in the stomach we might as well focus on that body part. The stomach produces acids to break down the food taken in and eventually digest it. This particular acid or also known as gastric acid is very strong but the stomach and duodenum is able to live with it since it is protected by a lining of mucus. But if that particular lining on the stomach is broken down or eroded thus, the sensitive tissue is below is exposed to the acid. The acid comes in contact into the wall of your stomach or duodenum that damages the part thus, causing ulcer to arise. Many symptoms arise once a person has peptic ulcer. One is abdominal pains, bloating and abdominal fullness, waterbash or the rush of saliva after diluting acid down the esophagus, nausea, hematemesis or when a person starts vomiting blood, melena and rarely ulcer may direct to a much complicated disease called gastric or duodenal perforation, which eventually may direct to acute peritonitis. This time it already very painful and the person would really need to take surgery. This type of illness may cause many types of complication such as gastrointestinal bleeding being the most common complication, perforation which is basically a whole on the wall of the stomach, the ulcer continuing to move and eventually be adjacent to the pancreas and liver and other adjacent organs, scarring and swelling and cancer being the most feared complication. But the pathophysiology of peptic ulcer may involve a much braoder value if take into the next level of necessary actions.

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Complications:
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Gastrointestinal bleeding is the most common complication. Sudden large bleeding can be lifethreatening.[5] It occurs when the ulcer erodes one of the blood vessels, such as the gastroduodenal artery.

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Perforation (a hole in the wall) often leads to catastrophic consequences. Erosion of the gastrointestinal wall by the ulcer leads to spillage of stomach or intestinal content into the abdominal cavity. Perforation at the anterior surface of the stomach leads to acute peritonitis, initially chemical and later bacterial peritonitis. The first sign is often sudden intense abdominal pain. Posterior wall perforation leads to pancreatitis; pain in this situation often radiates to the back. Penetration is when the ulcer continues into adjacent organs such as the liver and pancreas.[6] Scarring and swelling due to ulcers causes
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narrowing in the duodenum and gastric outlet obstruction. Patient often presents with severe vomiting.
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Cancer is included in the differential diagnosis (elucidated by biopsy), Helicobacter pylori as the etiological factor making it 3 to 6 times more likely to develop stomach cancer from the ulcer.[7] Internal bleeding. Bleeding can occur as slow blood loss that leads to anemia or as severe blood loss that may require hospitalization or a blood transfusion.

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Infection. Peptic ulcers can eat a hole through the wall of your stomach or small intestine, putting you at risk of serious infection of your abdominal cavity (peritonitis).

Scar tissue. Peptic ulcers can also produce scar tissue that can block passage of food through the digestive tract, causing you to become full easily, to vomit and to lose weight.

Anaemia If the bleeding from the ulcer is slow, you might not see blood in your vomit or faeces. However, you may develop anaemia. Anaemia is when there are too few red blood cells or not enough haemoglobin in the blood.

Bleeding Occasionally ulcers can cause the lining of your stomach or small bowel to bleed. If this happens suddenly, symptoms may include: vomiting blood - it may be bright red or like coffee

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grains (dark brown bits of clotted blood) dark faeces that look black or like tar - this is because the blood from the bleeding ulcer will have been partially broken down as it makes its way through the bowel If you have any of these symptoms, see your GP immediately. &Pyloric stenosis Pyloric stenosis can result if you have a peptic ulcer that causes long-term inflammation in the lining of your stomach or small bowel. This is a narrowing of the small passage called the pylorus that links your stomach and the first part of your small bowel. The main symptom of pyloric stenosis is vomiting.

Management :
Treatments and drugs Treatment for peptic ulcers typically involves antibiotics to kill the H. pylori bacterium and other medications to reduce the level of acid in your digestive system to relieve pain and encourage healing. You may take antibiotics for two weeks and acid-reducing medications for about two months. If your peptic ulcer isn't caused by H. pylori, you won't need antibiotics. Instead, your doctor may recommend treatments for your specific situation. For instance, if pain relievers caused your ulcer, your doctor may recommend a different pain reliever or a different dose. Your doctor may also recommend acid-reducing medications to allow your ulcer to heal. You may take these medications for two months or more.

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Treatments for peptic ulcer can include: Antibiotic medications to kill H. pylori. If H. pylori is found in your digestive tract, your doctor may recommend a combination of antibiotics to kill the bacterium. Antibiotic regimens are different throughout the world. In the United States, antibiotics prescribed for treatment of H. pylori include amoxicillin, clarithromycin (Biaxin), metronidazole (Flagyl) and tetracycline. You'll likely need to take antibiotics for two weeks. Medications that block acid production and promote healing. Proton pump inhibitors reduce acid by blocking the action of the parts of cells that produce acid. These drugs include the prescription and overthe-counter medications omeprazole (Prilosec), lansoprazole (Prevacid), rabeprazole (Aciphex), esomeprazole (Nexium) and pantoprazole (Protonix). Long-term use of proton pump inhibitors, particularly at high doses, may increase your risk of hip, wrist and spine fracture. Ask your doctor whether a calcium supplement may reduce this risk. Medications to reduce acid production. Acid blockers also called histamine (H-2) blockers reduce the amount of acid released into your digestive tract, which relieves ulcer pain and encourages healing. Available by prescription or over-the-counter (OTC), acid blockers include the medications ranitidine (Zantac), famotidine (Pepcid), cimetidine (Tagamet) and nizatidine (Axid). Antacids that neutralize stomach acid. Your doctor may include an antacid in your drug regimen. Antacids neutralize existing stomach acid and can provide rapid pain relief. Side effects can include
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constipation or diarrhea, depending on the main ingredients.

Medications that protect the lining of your stomach and small intestine. In some cases, your doctor may prescribe medications called cytoprotective agents that help protect the tissues that line your stomach and small intestine. They include the prescription medications sucralfate (Carafate) and misoprostol (Cytotec). Another nonprescription cytoprotective agent is bismuth subsalicylate (Pepto-Bismol). Goal: HP eradication, healing of ulcers, prevention of recurrences and complications of ulcer.

DRUG TREATMENT OF GASTRODUODENAL ULCERS ASSOCIATED WITH HP.

HP eradication regimen includes use of antibiotics and antacids (level A recommendations). Prolonged antacid use for treatment of ulcers caused by HP is not recommended (level B recommendations). Successful HP eradication decreases the recurrence rate from 90% to less than 5% a year. 1. Seven day regimen:May be taken 10-14 days, however, there is no data available to show the benefits of a 10- to 14-day regimen as compared to a

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y seven-day regimen A
Omeprasol (Losek, Omez) from other analogues currently recommended is Lansoprasol (Zoton) 20 mg bid or 30 mg bid (in the morning and in the evening before the meal, no later than 8 P.M. with mandatory 12-hour interval); capsule should be swallowed, not chewed Klarythromicin (Klacide) 250 mg bid Metronidazole (Trikhopole and other analogues) 500 mg bid at the end of the meal. The drug should not be taken with alcohol; metallic taste and/or dark urine are possible. Eradication rate 87-91%. B Omeprasol (Losek, Omez) from other analogues currently recommended is Lansoprasol (Zoton) 20 mg bid or 30 mg bid (in the morning and in the evening before the meal, no later than 8 P.M. with mandatory 12-hour interval); capsule should be swallowed, not chewed Klarythromicin (Klacide) 250 mg bid Amoxicillin 1g bid at the end of the meal. Amoxicillin is recommended in case of prior Metronidazole failure. Metronidazole is recommended for use in case of hypersensitivity to penicillin. Eradication rate 80-90%. C Omeprasol (Losek and analogues) 20 mg bid (in the
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morning and in the evening, no later than 8 P.M. with mandatory 12-hour interval) Amoxicillin (Flemoksyn Solutab, Kchikoniil and other analogues) 1 g/bid at the end of the meal Metronidazole (Trikhopole and other analogues) 500 mg bid at the end of the meal. Eradication rate 77-83%.

D Pylorid (Ranitidin Bismuth Citrate) 400 mg bid at the end of the meal Klarythromycin (Klacide) 250 mg/bid or tetracycline 500 mg four times a day or Amoxicillin 1000 mg/bid Metronidazole (Trikhopole and other analogues) 500 mg bid during the meal Eradication rate 78-83%. E Omeprasol (Losek and analogues 20 mg/bid (in the morning and in the evening, no later than 8 P.M. with mandatory 12-hour interval) Colloid Subcitrate of Bysmuth (Ventrisol, Denol and other analogues) 240 mg/bid 30 minutes before the meal (breakfast or supper) or 120 mg/q.i.d (first three doses should be taken 30 minutes before breakfast or dinner, or supper. The last two after the meal before going to bed).With this medication the tongue and the feces may develop dark color; half an hour before and after taking the
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medication it is not recommended to drink milk; it should be used with caution in patients hypersensitive to aspirin; in case of tinnutis the medication should be discontinued Metronidazole 250 mg/qid after the meal or Tinidazole 500 mg/bid after the meal Tetracyclin or amoxicillin 500 mg/qid after the meal Eradication rate in tetracyclin regimen 88-90%, in amoxicillin regimen 80-86%

2. Two-week regimens A
Ranitidin (Zantak and other analogies) 150 mg/bid or Famotidin (Gastrosydyn, Kvamatel, Ulfamyd) 20 mg/bid in the morning and in the evening (no later than 8 P.M.) with mandatory 12-hour interval; Potassium salt of bismuth citrate gastrostat 120 mg/qid before the meal Metronidazole 250 mg/qid after meal Tetracyclin hydrochloride 250 mg /qid after meals. Tetracyclin should not be used with dairy products, antacids and medications containing iron; photosensitization in the sun and a rash may develop Eradication rate 80% B Potassium salt of bismuth citrate gastrostat 120 mg/qid before the meal
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 Metronidazole 250 mg/qid after meal Tetracyclin hydrochloride 250 mg/qid after meals Eradication rate 75% Comments: Resistance may develop in regimens with Metronidazole and Klarythromycin Smoking hinders healing of ulcers and is associated with increased recurrence rate In absence of symptoms, diagnostic procedures to confirm successful eradication may be omitted. In case of complicated ulcer, endoscopy is indicated to confirm the success of the therapy.

Refractory ulcer.
The most common causes of refractory and recurrent ulcer include 1) ineffective eradication therapy; 2) unidentified use of NSAID and poor compliance with medications regimens, incomplete healing of large ulcers, Zollinger-Ellison syndrome and malignant neoplasms. Should the first stage oftherapy fail, a second stage of eradication therapy with other antibiotics is recommended; term of the therapy: 14 days. Treatment success in the case of gastric and gastrojejunal ulcers is monitored endoscopically in eight weeks; in the case of complicated duodenal ulcer; in 4 weeks. Use of serology testing to confirm eradication of HP is not justified, since antibody titer remains elevated even in the absence of HP.

TREATMENT OF ULCERS CAUSED BY NSAID

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NSAID use should be discontinued. Acetaminophen is as effective as NSAID in treatment of mild/severe arthritis. Routine HP evaluation of patients complaining of dyspepsia for NSAID is currently not recommended. In those cases when NSAID cannot be discontinued a 20 mg, single dose for four weeks of Omeprasol (or its analogues) is recommended. Clinical trials have shown that percentage of healing reaches 75-80% for an eight-week treatment. If NSAID can be discontinued, ranitidin (or its analogues) is recommended: 150 mg/bid for 8 weeks. To prevent peptic ulcer development in patients taking NSAID with associated risk factors (history of peptic ulcer or gastric bleeding, older than 75, history of cardiovascular problems), a simultaneous prescription of Misoprostole 200 mg/three times a day is recommended. To prevent gastric and duodenal ulcer recurrence and their complications: 1. Prophylactic therapy on demandstipulating administration of one of antacids (Ranitidin, Famotidin, Omeprasol) in a daily dose for 2-3 days, and then one half of the dose for two weeks in case of onset of symptoms characteristic for the exacerbation of ulceris recommended. If the symptoms of the exacerbation disappear, the therapy is discontinued. If they persist, EFGDS and other evaluation procedures envisaged by this protocol are indicated. 2. Continuous supportive therapy (for a month or even years) with half the dose of antacid. For example, one should take every evening: 150 mg of Ranitidin or 20 mg Famotidine (gastrosidin, kvamatel, ulfamide). Indications for this
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type of therapy include: complications of ulcer (ulcer-related bleeding or perforated ulcer) concurrent ulcerative -erosive esophageal reflux patients 60+ with annual recurrences of ulcer, despite adequate therapy

Treatment of Gastroduodenal ULCERS NOT ASSOCIATED WITH HP.

To exclude or reduce smoking and alcohol use as well as NSAID use, one of the following drug combinations and regimens is used: 1. Ranitidin (Zantak and other analogues) 300 mg a day, single dose at 78 P.M. and antacid (Maaloks, Remagel, Gastrin gel, etc.) as symptomatic medication 2. Famotidin (Gastrosidin, Kvamatel, Ulfamid) 40 mg a day at 78 P.M. and antacid (Maaloks, Remagel, Gastrin gel, etc.) as symptomatic medication 3. Sukralfat (Venter, Sukrat gel) 4 g a day; more often 1 g 30 min. before the meal and in the evening two hours after the meal for four weeks, then 2 g a day for eight weeks. For the treatment of refractory duodenal ulcers not associated with HP, maximal dose of proton pump inhibitors is recommended (Omeprasol, etc.). Concurrent use of proton pump inhibitors (PPI) and 2nd type histamine receptors blockers (HRB) is not recommended due to the potential decrease in the PPI effectiveness of. In cases of ulcers refractory to HRB-2, PPI is recommended (level A).

Recommendation levels:
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A Randomized clinical trials or meta-analysis with statistically valid results B Randomized clinical trials or meta-analysis in which clinical outcome is possible but not valid C Non-randomized clinical trials, the physician makes his own decision D Recommendations of panel, results of separate clinical observations The best way to stop any further growth of your stomach ulcer is to follow a healthy diet. It must contain nonacidic meals along with liquid meals. Sour agents like lemon should be strictly avoided in the diet.[20] Younger patients with ulcer-like symptoms are often treated with antacids or H2 antagonists before EGD is undertaken. Bismuth compounds may actually reduce or even clear organisms, though the warning labels of some bismuth subsalicylate products indicate that the product should not be used by someone with an ulcer.[clarification needed] Patients who are taking nonsteroidal antiinflammatories (NSAIDs) may also be prescribed a prostaglandinanalogue (Misoprostol) in order to help prevent peptic ulcers, which may be a side-effect of the NSAIDs. When H. pylori infection is present, the most effective treatments are combinations of 2 antibiotics (e.g. Clarithromycin, Amoxicillin, Tetracycline, Metronidazole) and 1 proton pump inhibitor (PPI), sometimes together with a bismuth compound. In complicated, treatment-resistant cases, 3 antibiotics (e.g. amoxicillin + clarithromycin + metronidazole) may be used together with a PPI and sometimes with
34

bismuth compound. An effective first-line therapy for uncomplicated cases would be Amoxicillin + Metronidazole + Pantoprazole (a PPI). In the absence of H. pylori, long-term higher doses PPIs are often used. Treatment of H. pylori usually leads to clearing of infection, relief of symptoms and eventual healing of ulcers. Recurrence of infection can occur and retreatment may be required, if necessary with other antibiotics. Since the widespread use of PPI's in the 1990s, surgical procedures (like "highly selective vagotomy") for uncomplicated peptic ulcers became obsolete. Perforated peptic ulcer is a surgical emergency and requires surgical repair of the perforation. Most bleeding ulcers require endoscopy urgently to stop bleeding with cautery, injection, or clipping. Ranitidine provides relief of peptic ulcers, heartburn, indigestion and excess stomach acid and prevention of these symptoms associated with excessive consumption of food and drink. Ranitidine is available over the counter from a pharmacy and works by decreasing the amount of acid the stomach produces allowing healing of ulcers. Zantac tablets contain Ranitidine 150 mg as the active ingredient which can also be bought generically. Follow-up after initial treatment Treatment for peptic ulcers is often successful, leading to ulcer healing. But if your symptoms are severe or if they continue despite treatment, your doctor may recommend endoscopy to rule out other possible causes for your symptoms. If an ulcer is detected during endoscopy, your doctor may recommend another
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endoscopy after your treatment to make sure your ulcer has healed. Ask your doctor whether you should undergo follow-up tests after your treatment. Ulcers that fail to heal Peptic ulcers that don't heal with treatment are called refractory ulcers. There are many reasons why an ulcer may fail to heal. These reasons may include: Not taking medications according to directions. The fact that some types of H. pylori are resistant to antibiotics. Regular use of tobacco. Regular use of pain relievers that increase the risk of ulcers. Less often, refractory ulcers may be a result of: Extreme overproduction of stomach acid, such as occurs in Zollinger-Ellison syndrome An infection other than H. pylori Stomach cancer Other diseases that may cause ulcer-like sores in the stomach and small intestine, such as Crohn's disease Treatment for refractory ulcers generally eliminating factors that may interfere with healing, along with using different antibiotics. Surgery and Other Procedures If bleeding from an ulcer does not stop by using medications and supportive care (like fluids and blood transfusion), a physician called a gastroenterologist will perform an endoscopy. He first identifies the ulcer
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involves

and the area that is bleeding, then injects medications to stop the bleeding and stimulate the formation of a blood clot. If the bleeding recurs or you have a perforated ulcer or an obstruction, surgery may be required. About 30% of people who come to the hospital with a bleeding ulcer need endoscopy or surgery. Nutrition and Dietary Supplements Following these nutritional tips may help reduce symptoms:
y

y y

Foods containing flavonoids, like apples, celery, cranberries (including cranberry juice), onions, garlic, and tea may inhibit the growth of H. pylori. Eat antioxidant foods, including fruits (such as blueberries, cherries, and tomatoes), and vegetables (such as squash and bell peppers). Eat foods high in B-vitamins and calcium, such as almonds, beans, whole grains (if no allergy), dark leafy greens (such as spinach and kale), and sea vegetables. Avoid refined foods, such as white breads, pastas, and sugar. Eat fewer red meats and more lean meats, coldwater fish, tofu (soy, if no allergy) or beans for protein. Use healthy oils, such as olive oil or vegetable oil. Reduce or eliminate trans-fatty acids, found in commercially baked goods such as cookies, crackers, cakes, French fries, onion rings, donuts, processed foods, and margarine. Avoid beverages that may irritate the stomach lining or increase acid production including coffee (with or without caffeine), alcohol, and carbonated beverages.
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y y

Drink 6 - 8 glasses of filtered water daily. Exercise at least 30 minutes daily, 5 days a week.

These supplements may also help:

y

Probiotic supplement (containing Lactobacillus acidophilus), 5 - 10 billion CFUs (colony forming units) a day -- Probiotics or friendly bacteria may help maintain a balance in the digestive system between good and harmful bacteria such as H. pylori. Probiotics may help suppress H. pylori infection and may also help reduce side effects from taking antibiotics, the treatment for an H. pylori infection. Some probiotic supplements may need to be refrigerated for best results. Vitamin C, 500 - 1,000 mg 1 - 3 times daily -- One study found that taking vitamin C along with triple therapy allowed the dose of one antibiotic to be lower. Vitamin C may also be helpful in treating bleeding stomach ulcers caused by aspirin use.

Choose a healthy diet. Choose a healthy diet full of fruits, vegetables and whole grains. Not eating vitamin-rich foods may make it difficult for your body to heal your ulcer. Consider switching pain relievers. If you use pain relievers regularly, ask your doctor whether acetaminophen (Tylenol, others) may be an option for you. Control stress. Stress may worsen the signs and symptoms of a peptic ulcer. Examine your life to determine the sources of your stress and do what you can to address those causes. Some stress is unavoidable, but you can learn to cope with stress with exercise, spending time with friends or writing in a journal.
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Don't smoke. Smoking may interfere with the protective lining of the stomach, making your stomach more susceptible to the development of an ulcer. Smoking also increases stomach acid. Limit or avoid alcohol. Excessive use of alcohol can irritate and erode the mucous lining in your stomach and intestines, causing inflammation and bleeding.

Prevention : You may reduce your risk of peptic ulcer if you: Protect yourself from infections. It's not clear just how H. pylori spreads, but there's some evidence that it could be transmitted from person to person or through food and water. You can take steps to protect yourself from infections, such as H. pylori, by frequently washing your hands with soap and water and by eating foods that have been cooked completely. Use caution with pain relievers. If you regularly use pain relievers that increase your risk of peptic ulcer, take steps to reduce your risk of stomach problems. For instance, take your medication with meals. Work with your doctor to find the lowest dose possible that still gives you pain relief. Avoid drinking alcohol when taking your medication, since the two can combine to increase your risk of stomach upset Preventing NSAID-related ulcers means finding different medications or alternative approaches to relieve your pain. Talk to your doctor about your options. If you have to take NSAIDs for a long time, your doctor may consider prescribing another medication to prevent the development of ulcers. This medicine may
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include an H2 blocker or a proton pump inhibitor, which reduce stomach acid. You can also make lifestyle changes that make you less prone to get an ulcer from either NSAIDs or H. pylori.

Interventions 1. Assess, report , and record signs and symptoms and reactions to treatment. 2. Monitor fluids input and output closely. 3. Administer antacid agents, analgesics, H2-receptors antagonists, anticholinergics, sedatives as prescribed, monitor for side effects. 4. Monitor clients vital signs and signs of possible GI bleeding or perforation closely. 5. Monitor laboratory tests results (CBC, electrolytes, Hb levels) for abnormal values. 6. Undertake appropriate intervention in case of GI bleeding, vomiting, or perforation. 7. Provide prescribed diet avoid irritating foods, coffee, etc. 8. Prepare client and his family for surgical intervention if required for recurrent ulcer, hemorrhage, or perforation. 9. For client after surgical intervention provide postoperative care and inform about possible postoperative complications, such as dumping syndrome. 10. Provide emotional support to client, explain all procedures to decrease anxiety and to obtain cooperation. 11. Instruct client regarding disease progress, diagnostic procedures, treatment and its
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complications, home care, daily activities, diet, restrictions and follow-up.

Evaluation 1. Reports increased comfort, decreased anxiety. 2. Verbalizes absence of heartburn and pain. 3. No evidence of nausea, vomiting, GI bleeding, or acute abdomen. 4. Maintains stable vital signs, fluid balance, and body weight. 5. Laboratory tests results shows no abnormalities. 6. No postoperative complications. 7. Demonstration of understanding of disease progress, diagnostic and treatment procedures, prevention, and need for follow-up.

Duodenal Ulcer

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A duodenal ulcer is usually caused by an infection with a bacterium (germ) called H. pylori. A 4-8 week course of acid-suppressing medication will allow the ulcer to heal. In addition, a one week course of two antibiotics plus an acid-suppressing drug will usually clear the H. pylori infection. This usually prevents the ulcer recurring again. Anti-inflammatory drugs used to treat conditions such as arthritis sometimes cause duodenal ulcers. If you need to continue with the antiinflammatory drug, then you may need to take long term acid-suppressing medication. What causes duodenal ulcers? Your stomach normally produces acid to help with the digestion of food and to kill bacteria. This acid is corrosive so some cells on the inside lining of the stomach and duodenum produce a natural mucus barrier which protects the lining of the stomach and duodenum. There is normally a balance between the amount of acid that you make and the mucus defense barrier. An ulcer may develop if there is an alteration in this balance allowing the acid to damage the lining of the stomach or duodenum. Causes of this include the following: Infection with Helicobacter pylori

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Infection by Helicobacter pylori (commonly just called H. pylori) is the cause in about 19 in 20 cases of duodenal ulcer. More than a quarter of people in the UK become infected with H. pylori at some stage in their life. Once you are infected, unless treated, the infection usually stays for the rest of your life. In many people it causes no problems and a number of these bacteria just live harmlessly in the lining of the stomach and duodenum. However, in some people this bacterium causes an inflammation in the lining of the stomach or duodenum. This causes the defence mucus barrier to be disrupted (and in some cases the amount of acid to be increased) which allows the acid to cause inflammation and ulcers. Anti-inflammatory drugs - including aspirin Anti-inflammatory drugs are sometimes called nonsteroidal anti inflammatory drugs (NSAIDs). There are various types and brands. For example: aspirin, ibuprofen, diclofenac, etc. Many people take an antiinflammatory drug for arthritis, muscular pains, etc. Aspirin is also used by many people to protect against blood clots forming. However, these drugs sometimes affect the mucus barrier of the duodenum and allow acid to cause an ulcer. About 1 in 20 duodenal ulcers are caused by anti-inflammatory drugs. Other causes and factors Other causes are rare. For example, the Zollinger-Ellison syndrome. In this rare condition, much more acid than usual is made by the stomach. Other factors such as smoking, stress, and drinking heavily may possibly increase the risk of having a duodenal ulcer. However, these are not usually the underlying cause of a duodenal ulcers. What are the symptoms of a duodenal ulcer?
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Pain in the upper abdomen just below the sternum (breastbone) is the common symptom. It usually comes and goes. It may occur most before meals, or when you are hungry. It may be eased if you eat food, or take antacid tablets. The pain may wake you from sleep. Other symptoms which may occur include: bloating, retching, and feeling sick. You may feel particularly 'full' after a meal. Sometimes food makes the pain worse. Complications occur in some cases, and can be serious. These include: o Bleeding ulcer. This can range from a 'trickle' to a life-threatening bleed. o Perforation. This is where the ulcer goes right through ('perforates') the wall of the duodenum. Food and acid in the duodenum then leak into the abdominal cavity. This usually causes severe pain and is a medical emergency.

What tests may be done?

y

Endoscopy is the test that can confirm a duodenal ulcer. In this test a doctor or nurse looks inside your stomach and duodenum by passing a thin, flexible telescope down your oesophagus. They can see any inflammation or ulcers. A test to detect the H. pylori bacterium is usually done if you have a duodenal ulcer. If H. pylori is found then it is likely to be the cause of the ulcer. See separate leaflet on Helicobacter Pylori Infection for more detail and how it can be diagnosed. Briefly, it can be detected in a sample of faeces, or in a 'breath test', or from a blood test, or from a biopsy sample taken during an endoscopy.
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What are the treatments for a duodenal ulcer? Acid suppressing medication A 4-8 week course of a drug that greatly reduces the amount of acid that your stomach makes is usually advised. The most commonly used drug is a proton pump inhibitor (PPI). These are a class (group) of drugs that work on the cells that line the stomach, reducing the production of acid. They include: esomeprazole, lansoprazole, omeprazole, pantoprazole and rabeprazole, and come in various brand names. Sometimes a drug from another class of drugs called H2 blockers is used. H2 blockers work in a different way on the cells that line the stomach, reducing the production of acid. They include: cimetidine, famotidine, nizatidine and ranitidine, and come in various brand names. As the amount of acid is greatly reduced, the ulcer usually heals. However, this is not the end of the story ... If your ulcer was caused by H. pylori Nearly all duodenal ulcers are caused by infection with H. pylori. Therefore, a main part of the treatment is to clear this infection. If this infection is not cleared, the ulcer is likely to return once you stop taking acidsuppressing medication. Two antibiotics are needed. In addition, you need to take an acid-suppressing drug to reduce the acid in the stomach. This is needed to allow the antibiotics to work well. You need to take this 'combination therapy' (sometimes called 'triple therapy') for a week. One course of combination therapy clears H. pylori infection in up to 9 in 10 cases. If H. pylori is cleared, the chance of a recurrence of a duodenal ulcer is greatly reduced. However, in a small number of people
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H. pylori infection returns at some stage in the future. After treatment, a test to check that H. Pylori has gone may be advised. If it is done it needs to be done at least four weeks after the course of combination therapy has finished. In most cases, the test is 'negative' meaning that the infection has gone. If it has not gone, then a repeat course of combination therapy with a different set of antibiotics may be advised. Some doctors say that for people with a duodenal ulcer, this 'confirmation' test is not necessary if symptoms have gone. The fact that symptoms have gone usually indicates that the ulcer and the cause (H. pylori) have gone. But, some doctors say it is needed to play safe. Your own doctor will advise if you should have it. (Note: a test to confirm that H pylori has gone is usually always recommended if you have a stomach ulcer.) If your ulcer was caused by an anti-inflammatory drug If possible, you should stop the anti-inflammatory drug. This allows the ulcer to heal. You will also normally be prescribed an acid-suppressing drug for several weeks (as mentioned above). This stops the stomach from making acid and allows the ulcer to heal. However, in many cases the anti-inflammatory drug is needed to ease symptoms of arthritis or other painful conditions, or aspirin is needed to protect against blood clots. In these situations, one option is to take an acidsuppressing drug each day indefinitely. This reduces the amount of acid made by the stomach, and greatly reduces the chance of an ulcer forming again. Surgery In the past, surgery was commonly needed to treat a duodenal ulcer. This was before it was discovered that H.
46

pylori was the cause of most duodenal ulcers, and before modern acid-suppressing drugs became available. Surgery is now usually only needed if a complication of a duodenal ulcer develops such as severe bleeding or a perforation.

Zollinger-Ellison Syndrome

What is Zollinger-Ellison Syndrome? Zollinger-Ellison Syndrome is a rare condition that causes severe stomach ulcers. It is characterized by tumors (gastrinomas) in the body. The tumors most commonly form in the pancreas and duodenum. The tumors cause ulcers because they secrete a substance called gastrin, which stimulates excessive acid secretion by the stomach. Ulcers associated with Zollinger-Ellison Syndrome are often difficult to control. They are more persistent and less responsive to treatments than usual ulcers are.

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Zollinger-Ellison Syndrome may occur at any age, but it is more likely to appear between the ages of 30 and 60 years old. Symptoms of Zollinger-Ellison Syndrome The most common symptoms of Zollinger-Ellison Syndrome are:
y y y y y

diarrhea abdominal pain bleeding fatigue and weakness yellow fat in stool

How serious is Zollinger-Ellison Syndrome? Zollinger-Ellison Syndrome is a serious condition. The tumors may spread to the lymph nodes and liver. The earlier it is detected, the better the chances of recovery. Treatment options for Zollinger-Ellison Syndrome Zollinger-Ellison Syndrome can be treated. If the tumors are big enough, the doctor may choose to perform surgery to remove the tumors. If the tumors are small or too numerous to be removed, the doctor will probably prescribe acid-reducing medication. The patient will probably have to take the medication for a long period of time. In very severe cases of Zollinger-Ellison Syndrome, the entire stomach may have to be surgically removed. How is Zollinger-Ellison Syndrome Diagnosed?

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Your doctor will perform blood tests, an upper endoscope examination and barium x-ray to determine if he thinks you have Zollinger-Ellison Syndrome.

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