Peptic ulcers NSAID-related

NSAIDs are one of the most widely used classes of medications in the United States, particularly in the elderly.4 More than 20,000 deaths occur in the United States per year as a direct result of adverse events related to NSAID use. Chronic NSAID ingestion leads to symptoms of nausea and dyspepsia in nearly half of patients. Peptic ulceration occurs in up to 30% of patients who use NSAIDs chronically, with gastrointestinal bleeding or perforation occurring in 1.5% of patients who develop an ulcer. NSAID-related peptic ulcers usually occur in the stomach duodenal ulcers are much less common. 

Peptic ulcer disease (PUD) refers to a group of ulcerative disorders of the upper GI tract that require acid and pepsin for their formation. Ulcers differ from gastritis and erosions in that they extend deeper into the muscularis mucosa. The three common forms of peptic ulcers include Helicobacter pylori (HP)-associated ulcers, nonsteroidal antiinflammatory drug (NSAID)-induced ulcers, and stress-related mucosal damage (also called stress ulcers). 

Asymptomatic peptic ulceration develops in 10-20% of people taking frequent NSAIDs, and ulcer-related complications (bleeding, perforation) develop in 1-2% of persons per year. Proton pump inhibitors taken once daily are effective in reducing the incidence of ulcers and ulcer complications in patients taking aspirin or other NSAIDs. 

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. 

Q10 Misoprostol is a synthetic PG analogue which is used to promote ulcer healing in patients who have ulceration related to use of NSAIDs, for example for chronic musculoskeletal pain. Its use can prevent the development of peptic ulcers as it has a protective effect on the mucosa. 

In the UK an estimated 12 000 peptic ulcer complications and 1200 deaths per year are attributable to NSAID use. Toxicity relates to anti-... 

Most peptic ulcers occur in the presence of acid and pepsin when HP, NSAIDs, or other factors (see Table 33-2) disrupt normal mucosal defense and healing mechanisms. Hypersecretion of acid is the primary pathogenic mechanism in hypersecretory states such as ZES. Ulcer location is related to a number of etiologic factors. Benign gastric ulcers can occur anywhere in the stomach, although most are located on the lesser curvature, just distal to the junction of the antral and acid-secreting mucosa (see Fig. 33-1). Most duodenal ulcers occur in the first part of the duodenum (duodenal bulb). 

The NSAID-sparing effect of capsaicin can reduce the unwanted side effects of NSAIDs such as platelet-related aggregation abnormalities, peptic ulcer problems, or cardiovascular and renal complications. It may be particularly useful in the elderly, who are often intolerant to opioids and NSAIDs. 

Gastric erosions are aphthous ulcers that do not penetrate the muscularis mucosa. They are most often related to H. pylori infection (Levine and Rubesin 1995). Other causative agents include alcohol, salicylates, and nonsteroidal anti-inflammatory drugs (NSAIDs). They are also seen in critically ill patients due to multiple trauma, sepsis, shock, etc. At double-contrast barium studies, gastric erosions appear as shallow small, 1-2-mm-diameter collections of barium surrounded by a radiolucent rim of oedema an appearance mirrored at endoscopy with a haemorrhagic centre and oedematous rim (Fig. 5.2a,b) (Levine and Rubesin 1995 Sohn et al. 1995 Dheer et al. 2002). H. pylori infection is also related to the presence of lymphoid follicular hyperplasia, which is commonly present in patients with peptic ulcer disease (Fig. 5.3a,b) (Torigian et al. 2001). 

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