Treatment of ulcerous disease, Helicobacter Pylori infection scheme

Treatment of ulcerous disease

1.The diet
A diet with avoidance of acid, hot or seasoned food might still be recommended. The exclusion of coffee during the acute period may be recommended.
Aspirin intake, as well as NSAIDS and corticoids should be forbidden.
2. Medical therapy
Administration of:
A) Antisecretory drugs
- H2 histaminic receptor blockers:

• Cimetidine 1000mg/day
• Ranitidine 300 mg/day
• Nizatidine(Axid) 300 mg/day
• Famotidine (Quamatel) 40mg/day

Famotidine will be preferred, given once or twice a day and without drug interferences of Cimetidine(cytochrome P450).
- HK ATP - ase pump blockers:

• Esomeprazole(Nexium) 40mg/day
• Omeprazole (Losec, Antra, Ultop) 40 mg/day
• Pantoprazole(Controloc) 40 mg/day
• Lanzoprazole(Lanzap) 30mg/day
• Rabeprazole(Pariet) 20mg/day

The duration of antisecretory therapy will be for 6-8 weeks.
B) Gastric mucosal protectives

• sucralfate 4g/day (qid)might be associated.

C) Antacids
To neutralize the acid excess and reduce the painful symptoms, symptomatic medication such as Maalox, Almagel, Alfogel etc. are used.
Schemes of treatment in Helicobacter Pylori infection
- The schemes including proton pump blockers (zomeprazole, lanzoprazole or pantoprazole), associated with two antibiotics are indicated, triple or even quadruple schemes are used.
 -The triple therapy includes OAM=Omeprazole(40mg/day)+Amoxicillin(2g/day)+Metronidazole(1500mg/day);
- or the ideal association is OAC=Omeprazole+Amoxicilline+Claritromicine(macrolide in dose of 1000mg/day).
- The quadruple therapy is composed of  Omeprazole+Subcitric bismuth (De-Nol)+Tetracycline+Metronidazole.
The anti HP therapy duration is for 7 day.
Some authors treat a newly discovered Helicobacter Pylori positive ulcer, only with 7 days of anti Helicobacter Pylori therapy. It is still generally preferred that this therapy be followed by one month of antisecretory medication-proton pump inhibitors.
The check-out of Helicobacter Pylori eradication may be done by endoscopy with biopsy (where Helicobacter Pylori may be ditectly pointed out) or by indirect tests (the ideal one being the respiratory test, or possibly the evidence of Helicobacter Pylori in the stool).
3. Endoscopic treatment – endoscopic hemostasis
 Hemostasis by injecting adrenaline 1/10.000 or sclerosant agents (etoxysclerol or even alcohol 90%) determines the stopping of hemorrhage by their vasoconstrictor effect and by compressive mechanic effect, resulted by injection.

Plasma photocoagulation with argon or laser produces a hemostasis by contact coagulation, up to a depth of 3-4 mm. It is used mostly in the diffuse bleedings.
The Rockall Score’is an externally validated mortality risk assessment score for patients admitted with upper gastrointestinal bleeding. It is simple and practical to use, helping identify those at highest risk of dying and needing active intervention. It also identifies those for safe, early discharge (initial score 0, final 2). The Rockall score quantifies the following parameters : age, pulse, systolic blood pressure, co-morbidity and endoscopic findings.
The endoscopic dilatation of pyloric stenosis may be made with small pneumatic balloons or sparking plugs, thus avoiding the trauma of a surgical intervention.
Mucosectomia of gastric ulcerous lesions with dysplasia or even with gastric cancer “in situ” is a method in full expansion, introduced by Japanese endoscopists, which allows the whole excision of premalignant or malignant lesions “in situ”. It has the advantage of avoiding the trauma of surgical intervention, but requires a precise preinterventional staging by echoendoscopy.
4. Surgical treatment
The indications are even more limited: hemorrhages that cannot be stopped endoscopically or pyloric stenosis that cannot be dilated endoscopically. The perforation and penetration are of course absolute indications for surgical intervention.