Peptic ulcer disease complications

The analgesic effects of NSAIDs are attributed to inhibition of the COX-2 enzyme, whereas the negative GI effects are due to inhibition of COX-1.28 Patients taking oral anticoagulants, those with a history of peptic ulcer disease, or others at high risk for GI complications may be considered candidates for a COX-2 inhibitor or a combination of a nonselective NSAID with a gastroprotective agent such as a proton pump inhibitor (PPI). Because most PPIs are available by prescription only, such patients should be referred to a physician. 

Although the risk of GI complications is relatively small with short-term therapy, coadministration with a proton pump inhibitor should be considered in elderly patients and others at increased GI risk. NSAIDs should be used with caution in individuals with a history of peptic ulcer disease, heart failure, uncontrolled hypertension, renal insufficiency, coronary artery disease, or if they are receiving anticoagulants concurrently. 

The author commented that 50-75% of gastrocolic fistulas are related to benign gastric ulcers secondary to the use of NSAIDs. The use of aspirin plus prednisone, as in this patient, increases the risk of complication of peptic ulcer disease two- to fourfold. 

All NSAIDs have the potential to cause gastric and duodenal ulcers and bleeding through direct (topical) or indirect (systemic) mechanisms. Risk factors for NSAID-associated ulcers and ulcer complications (perforation, gastric outlet obstruction, GI bleeding) include increased age, comorbid medical conditions (e.g., cardiovascular disease), concomitant corticosteroid or anticoagulant therapy, and history of peptic ulcer disease or upper Gl bleeding. 

Contraindications fc>r nonsalicylate NSAID therapy are the same as those for aspirin (see Box 7-I).The formation of a gastric ulcer or erosion that may bleed profusely is a serious potential problem with NSAIDs. Consequently, the nonsalicylate NSAIDs should be avoided or used with great caution in patients with active peptic ulcer disease. NSAIDs may increase the risk of GI complications even when used in conjunction with low-dose aspirin for cardioprotection. In addition, because of potential crosssensitivity to other NSAIDs, the nonsalicylate NSAIDs should not be given to patients in whom aspirin or other NSAIDs have caused symptoms of asthma, rhinitis, urticaria, angioedema, hypotension, bronchospasm, or of symptoms of hypersensitivity reactions. Opioids, tramadol, or acetaminophen may be suitable alternatives for patients with known or suspected susceptibility. 

Successful glucocorticoid therapy involves counseling the patient, monitoring the patient, and recognizing complications of therapy (Table 74—10). The riskibeneflt ratio of glucocorticoid administration should always be considered, especially with concurrent disease states such as hypertension, diabetes mellitus, peptic ulcer disease, and uncontrolled systemic infections. 

Peptic ulcer disease is one common illness that affects more than 6 million persons in the United States each year (Sandler et al. 2001) and is strongly linked wifii increased rate of cigarette smoking, alcohol intake, psychological stress, regular use of aspirin, and prolonged use of steroids. Infection with Helicobacter pylori also substantially increases the risk for peptic ulcer and its complications (Papatheodo-ridis et al. 2006). Essential oil of Cinnamomum zeylanicum also... 

Finally be aware of the fact that diseases in the upper part of the gastrointestinal tract are common in the elderly and can cause severe complications and even be fatal. Drugs that are often used in the elderly due to chronic diseases with inflammation and pain are often the cause of gastritis, peptic ulcers and hiatus hernia. The risks of medication side effects as a reason for the problem must be taken into account when treating elderly for peptic ulcers and stomach pain. 

Because side effects can complicate the use of corticosteroids, a careful history and certain tests may be advisable, particularly if a patient may require prolonged ocular therapy. Steroids should be used with great caution in patients with diabetes mellitus, infectious disease, chronic renal feilure, congestive heart feilure, and systemic hypertension. Systemic administration is generally contraindicated in patients with peptic ulcer, osteoporosis, or psychoses. Topical steroids should be used with caution and only when necessary in patients with glaucoma. 

The most common sites of GI injmy are the gastric and duodenal mucosae." The incidence of gastric ulcers with NSAID use is approximately 11% to 13%, and that for duodenal ulcers is 7% to 10%. Serious GI complications associated with NSAIDs, including perforations, gastric outlet obstruction, and GI bleeding, occur in 1.5% to 4% of patients per year. NSAIDs are so widely used that these small percentages translate into substantial morbidity and mortality. " Moreover, the risk increases to 9% per year for patients with the risk factors of advanced age, history of peptic ulcer or GI bleeding, or cardiovascular disease. Consequently, about 16,500 deaths are associated annually with NSAID use in rheumatoid arthritis or OA patients. 

The advent of H2RAS and PPIs has virtually abolished the need for peptic ulcer surgery except to deal with complications. For the most part, gastric resections are associated with a morbidity and are therefore avoided unless circumstances absolutely dictate surgical intervention. Gastric resections may be of some benefit in very early neoplastic disease of the stomach. 

Nevertheless, there does appear to be a group of patients in whom ulcers recur even after successful eradication of H. pylori. In such instances, once other causes of therapeutic failure (noncompliance, salicylate abuse, NSAIDs, gastrinoma) have been eliminated, maintenance antisecretory therapy should be considered. Long-term antisecretory agents should thus be reserved for individuals in whom at least two attempts at H. pylori eradication have failed or in those who have H. pylori-negatiwe peptic disease, and possibly in individuals with complicated ulcers, particularly those prone to recurrent bleeding. 

The complications of acid peptic disease usually represent the sequelae of long-standing or chronic ulceration. Occasionally, such events may occur in an acute setting, but in such circumstances, the acute presentation often represents administration of a drug such as an NSAID, aspirin, or alcohol or exposure to the stress of trauma or major surgery. For the most part, bleeding and perforation are the most dramatic and the most common, with penetration and obstruction being less frequent and far less acute in their presentations. 

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