Gastrik Hiperasidite, Peptik Ülser Hastalığı ve Proton Pompa İnhibitörü Kullanımı
Özet
Peptik ülser hastalığı (PÜH), mide veya duodenum mukozasında doku kaybı ile karakterize olan, morbidite ve mortalitesi yüksek bir hastalıktır. Dispepsi ve gastrit gibi sık görülen klinik tablolara benzemesi nedeniyle tanı ve yönetiminde dikkatli bir yaklaşım gerektirir. Dünya genelinde PÜH gelişiminde en önemli sebep Helicobacter pylori (H. pylori) enfeksiyonudur. Nonsteroid antienflamatuvar ilaç (NSAİİ) ve aspirin kullanımı, özellikle H. pylori negatif hastalarda ülser gelişiminin başlıca nedeni olarak değerlendirilir. PÜH patogenezinde, gastroduodenal mukozayı koruyan savunma mekanizmaları ile mide asidi ve pepsin gibi agresif faktörler arasındaki dengenin bozulması yer almaktadır. Hastalık klinik olarak sıklıkla epigastrik ağrı ile ortaya çıkar ancak ilk başvuru kanama veya perforasyon gibi daha ölümcül komplikasyonlarla da ortaya çıkabilir. Bu nedenle acil serviste epigastrik ağrı ile başvuran hastalarda, ayırıcı tanı geniş tutulmalıdır. Tanı büyük ölçüde klinik değerlendirme ile konulmasının yanında, üst gastrointestinal endoskopi yapılması kesin tanı ve komplikasyon yönetiminde altın standart olarak değerlendirilir. Tedavide proton pompa inhibitörleri birinci basamak ajanlarldandır. H. pylori eradikasyonu, ülser iyileşmesini hızlandırmakta ve nüks oranlarını belirgin şekilde azaltmaktadır. Komplikasyonsuz olgular uygun medikal tedavi ve hasta eğitimi ile taburcu edilebilirken, komplike hastalarda multidisipliner yaklaşım ve hastane yatışı gerekebilir.
Peptic ulcer disease is a condition characterized by mucosal tissue loss in the stomach or duodenum and is associated with high morbidity and mortality. Owing to its resemblance to commonly encountered clinical entities such as dyspepsia and gastritis, a careful approach is required in both diagnosis and management. Globally, Helicobacter pylori (H. pylori) infection represents the most important etiological factor in the development of peptic ulcer disease. The use of nonsteroidal anti-inflammatory drugs (NSAIDs) and aspirin is considered the leading cause of ulcer formation, particularly in H. pylori–negative patients. The pathogenesis of PUD involves a disruption of the balance between aggressive factors, including gastric acid and pepsin, and the protective mechanisms of the gastroduodenal mucosa. Clinically, the disease most commonly presents with epigastric pain; however, initial presentation may also occur with life-threatening complications such as gastrointestinal bleeding or perforation. Therefore, in patients presenting to the emergency department with epigastric pain, a broad differential diagnosis should be maintained. Although the diagnosis is largely based on clinical evaluation, upper gastrointestinal endoscopy is regarded as the gold standard for definitive diagnosis and the management of complications. Proton pump inhibitors constitute the first-line agents in medical therapy. Eradication of H. pylori significantly accelerates ulcer healing and markedly reduces recurrence rates. While uncomplicated cases can be safely discharged with appropriate medical treatment and patient education, complicated cases may require hospitalization and a multidisciplinary management approach.
Referanslar
Tintinalli J, Ma O, Yealy D, Meckler G, Stapczynski JS, Cline D, et al. Chapter 78: Peptic Ulcer Disease and Gastritis. İçinde: Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 9. baskı. New York: McGraw-Hill Education; 2020. s. 514-6.
Vakil N. Peptic Ulcer Disease: A Review. Journal of the American Medical Association. 2024;332(21):1832.
Kılıcarslan H, Kalyon S, Yenice N. Etiopathogenesis of Peptic Ulser. The Medical Journal of Okmeydanı Training and Research Hospital. 2013;27(2):65-9.
Fashner J, Gitu AC. Diagnosis and Treatment of Peptic Ulcer Disease and H. pylori Infection. American Academy of Family Physicians 2015;91(4):online. 2015;
Sipponen P, Varis K, Fräki O, Korri UM, Seppälä K, Siurala M. Cumulative 10-Year Risk of Symptomatic Duodenal and Gastric Ulcer in Patients with or without Chronic Gastritis: A Clinical Follow-up Study of 454 Outpatients. Scandinavian Journal of Gastroenterology. 1990;25(10):966-73.
Sonnenberg A. Temporal trends and geographical variations of peptic ulcer disease. Aliment Pharmacol Ther. 1995;9 Suppl 2:3-12.
Sung JJY, Tsoi KKF, Ma TKW, Yung MY, Lau JYW, Chiu PWY. Causes of Mortality in Patients With Peptic Ulcer Bleeding: A Prospective Cohort Study of 10,428 Cases. American Journal of Gastroenterology. 2010;105(1):84-9.
Lau JY, Sung J, Hill C, Henderson C, Howden CW, Metz DC. Systematic Review of the Epidemiology of Complicated Peptic Ulcer Disease: Incidence, Recurrence, Risk Factors and Mortality. Digestion. 2011;84(2):102-13.
Schubert ML. Physiologic, pathophysiologic, and pharmacologic regulation of gastric acid secretion. Current Opinion in Gastroenterology. 2017;33(6):430-8.
Lee SP, Sung IK, Kim JH, Lee SY, Park HS, Shim CS. Risk Factors for the Presence of Symptoms in Peptic Ulcer Disease. Clinical Endoscopy. 2017;50(6):578-84.
Walls R, Hockberger R, Gausche-Hill M, Bakes K, Zink BJ. Bölüm 74, Özofagus, Mide ve Duodenum Hastalıkları. Rosen Acil Tıp: Kavramlar ve Klinik Uygulama. 9. BASKI. İstanbul: Güneş Tıp Kitabevleri; 2019. s. 1103-26.
Xie L, Liu GW, Liu YN, Li PY, Hu XN, He XY, et al. Prevalence of Helicobacter pylori infection in China from 2014-2023: A systematic review and meta-analysis. World Journal of Gastroenterology. 2024;30(43):4636-56.
Huang JQ, Sridhar S, Hunt RH. Role of Helicobacter pylori infection and non-steroidal anti-inflammatory drugs in peptic-ulcer disease: a meta-analysis. The Lancet. 2002;359(9300):14-22.
Gururatsakul M, Holloway RH, Talley NJ, Holtmann GJ. Association between clinical manifestations of complicated and uncomplicated peptic ulcer and visceral sensory dysfunction. Journal of Gastroenterology and Hepatology. 2010;25(6):1162-9.
Tonolini M, Ierardi AM, Bracchi E, Magistrelli P, Vella A, Carrafiello G. Non-perforated peptic ulcer disease: multidetector CT findings, complications, and differential diagnosis. Insights into Imaging. 2017;8(5):455-69.
Vakil N. Endoscopic Diagnosis, Grading, and Treatment of Bleeding Peptic Ulcer Disease. Gastrointestinal Endoscopy Clinics of North America. 2024;34(2):217-29.
Wolfe MM, Sachs G. Acid suppression: Optimizing therapy for gastroduodenal ulcer healing, gastroesophageal reflux disease, and stress-related erosive syndrome. Gastroenterology. 2000;118(2):S9-31.
Laine L, Barkun AN, Saltzman JR, Martel M, Leontiadis GI. ACG Clinical Guideline: Upper Gastrointestinal and Ulcer Bleeding. American Journal of Gastroenterology. 2021;116(5):899-917.
Vakil NB Overview of complications of peptic ulcer disease Post TW, ed UpToDate Waltham, MA: UpToDate Inc Accessed October 23, 2020b http://www.uptodate.com).
Kanebratt K, Diczfalusy U, Bäckström T, Sparve E, Bredberg E, Böttiger Y, et al. Cytochrome P450 Induction by Rifampicin in Healthy Subjects: Determination Using the Karolinska Cocktail and the Endogenous CYP3A4 Marker 4β-Hydroxycholesterol. Clinical Pharmacology & Therapeutics. 2008;84(5):589-94.
Hata M, Hayasaka M, Sezai A, Niino T, Yoda M, Unosawa S, et al. Proton Pump Inhibitors May Increase the Risk of Delayed Bleeding Complications after Open Heart Surgery if Used Concomitantly with Warfarin. The Thoracic and Cardiovascular Surgeon. 2008;56(05):274-7.
Unge P, Svedberg L, Nordgren A, Blom H, Andersson T, Lagerstrom P, et al. A study of the interaction of omeprazole and warfarin in anticoagulated patients. British Journal of Clinical Pharmacology. 1992;34(6):509-12.
Kwok CS, Arthur AK, Anibueze CI, Singh S, Cavallazzi R, Loke YK. Risk of Clostridium difficile Infection With Acid Suppressing Drugs and Antibiotics: Meta-Analysis. American Journal of Gastroenterology. 2012;107(7):1011-9.
Cheungpasitporn W, Thongprayoon C, Kittanamongkolchai W, Srivali N, Edmonds PJ, Ungprasert P, et al. Proton pump inhibitors linked to hypomagnesemia: a systematic review and meta-analysis of observational studies. Renal Failure. 2015;37(7):1237-41.
Ajmera AV, Shastri GS, Gajera MJ, Judge TA. Suboptimal Response to Ferrous Sulfate in Iron-Deficient Patients Taking Omeprazole. American Journal of Therapeutics. 2012;19(3):185-9.
Lam JR, Schneider JL, Zhao W, Corley DA. Proton Pump Inhibitor and Histamine 2 Receptor Antagonist Use and Vitamin B12 Deficiency. Journal of the American Medical Association. 2013;310(22):2435.
Ahn JS, Park SM, Eom CS, Kim S, Myung SK. Use of Proton Pump Inhibitor and Risk of Colorectal Cancer: A Meta-analysis of Observational Studies. Korean Journal of Family Medicine. 2012;33(5):272.
Oates JA, Wood AJJ, Feldman M, Burton ME. Histamine2 -Receptor Antagonists: Standard Therapy for Acid-Peptic Diseases. New England Journal of Medicine. 13 Aralık 1990;323(24):1672-80.
Meng R, Chen L, Zhang M, Cai W, Yin S, Fan Y, et al. Effectiveness and Safety of Histamine H2 Receptor Antagonists: An Umbrella Review of Meta‐Analyses. The Journal of Clinical Pharmacology. 2023;63(1):7-20.
Konturek SJ. New aspects of clinical pharmacology of antacids. Journal of Physiology and Pharmacology: An Official Journal of the Polish Physiological Society. 1993;44(3 Suppl 1):5-21.
Moss SF, Shah SC, Tan MC, El-Serag HB. Evolving Concepts in Helicobacter pylori Management. Gastroenterology. 2024;166(2):267-83.
Coşar AM, Özgür O Peptik ülserde Helicobacter pylori tedavisi Turkiye Klinikleri Journal Gastroenterohepatology-Special Topics 2013;6(1):49-55.
Referanslar
Tintinalli J, Ma O, Yealy D, Meckler G, Stapczynski JS, Cline D, et al. Chapter 78: Peptic Ulcer Disease and Gastritis. İçinde: Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 9. baskı. New York: McGraw-Hill Education; 2020. s. 514-6.
Vakil N. Peptic Ulcer Disease: A Review. Journal of the American Medical Association. 2024;332(21):1832.
Kılıcarslan H, Kalyon S, Yenice N. Etiopathogenesis of Peptic Ulser. The Medical Journal of Okmeydanı Training and Research Hospital. 2013;27(2):65-9.
Fashner J, Gitu AC. Diagnosis and Treatment of Peptic Ulcer Disease and H. pylori Infection. American Academy of Family Physicians 2015;91(4):online. 2015;
Sipponen P, Varis K, Fräki O, Korri UM, Seppälä K, Siurala M. Cumulative 10-Year Risk of Symptomatic Duodenal and Gastric Ulcer in Patients with or without Chronic Gastritis: A Clinical Follow-up Study of 454 Outpatients. Scandinavian Journal of Gastroenterology. 1990;25(10):966-73.
Sonnenberg A. Temporal trends and geographical variations of peptic ulcer disease. Aliment Pharmacol Ther. 1995;9 Suppl 2:3-12.
Sung JJY, Tsoi KKF, Ma TKW, Yung MY, Lau JYW, Chiu PWY. Causes of Mortality in Patients With Peptic Ulcer Bleeding: A Prospective Cohort Study of 10,428 Cases. American Journal of Gastroenterology. 2010;105(1):84-9.
Lau JY, Sung J, Hill C, Henderson C, Howden CW, Metz DC. Systematic Review of the Epidemiology of Complicated Peptic Ulcer Disease: Incidence, Recurrence, Risk Factors and Mortality. Digestion. 2011;84(2):102-13.
Schubert ML. Physiologic, pathophysiologic, and pharmacologic regulation of gastric acid secretion. Current Opinion in Gastroenterology. 2017;33(6):430-8.
Lee SP, Sung IK, Kim JH, Lee SY, Park HS, Shim CS. Risk Factors for the Presence of Symptoms in Peptic Ulcer Disease. Clinical Endoscopy. 2017;50(6):578-84.
Walls R, Hockberger R, Gausche-Hill M, Bakes K, Zink BJ. Bölüm 74, Özofagus, Mide ve Duodenum Hastalıkları. Rosen Acil Tıp: Kavramlar ve Klinik Uygulama. 9. BASKI. İstanbul: Güneş Tıp Kitabevleri; 2019. s. 1103-26.
Xie L, Liu GW, Liu YN, Li PY, Hu XN, He XY, et al. Prevalence of Helicobacter pylori infection in China from 2014-2023: A systematic review and meta-analysis. World Journal of Gastroenterology. 2024;30(43):4636-56.
Huang JQ, Sridhar S, Hunt RH. Role of Helicobacter pylori infection and non-steroidal anti-inflammatory drugs in peptic-ulcer disease: a meta-analysis. The Lancet. 2002;359(9300):14-22.
Gururatsakul M, Holloway RH, Talley NJ, Holtmann GJ. Association between clinical manifestations of complicated and uncomplicated peptic ulcer and visceral sensory dysfunction. Journal of Gastroenterology and Hepatology. 2010;25(6):1162-9.
Tonolini M, Ierardi AM, Bracchi E, Magistrelli P, Vella A, Carrafiello G. Non-perforated peptic ulcer disease: multidetector CT findings, complications, and differential diagnosis. Insights into Imaging. 2017;8(5):455-69.
Vakil N. Endoscopic Diagnosis, Grading, and Treatment of Bleeding Peptic Ulcer Disease. Gastrointestinal Endoscopy Clinics of North America. 2024;34(2):217-29.
Wolfe MM, Sachs G. Acid suppression: Optimizing therapy for gastroduodenal ulcer healing, gastroesophageal reflux disease, and stress-related erosive syndrome. Gastroenterology. 2000;118(2):S9-31.
Laine L, Barkun AN, Saltzman JR, Martel M, Leontiadis GI. ACG Clinical Guideline: Upper Gastrointestinal and Ulcer Bleeding. American Journal of Gastroenterology. 2021;116(5):899-917.
Vakil NB Overview of complications of peptic ulcer disease Post TW, ed UpToDate Waltham, MA: UpToDate Inc Accessed October 23, 2020b http://www.uptodate.com).
Kanebratt K, Diczfalusy U, Bäckström T, Sparve E, Bredberg E, Böttiger Y, et al. Cytochrome P450 Induction by Rifampicin in Healthy Subjects: Determination Using the Karolinska Cocktail and the Endogenous CYP3A4 Marker 4β-Hydroxycholesterol. Clinical Pharmacology & Therapeutics. 2008;84(5):589-94.
Hata M, Hayasaka M, Sezai A, Niino T, Yoda M, Unosawa S, et al. Proton Pump Inhibitors May Increase the Risk of Delayed Bleeding Complications after Open Heart Surgery if Used Concomitantly with Warfarin. The Thoracic and Cardiovascular Surgeon. 2008;56(05):274-7.
Unge P, Svedberg L, Nordgren A, Blom H, Andersson T, Lagerstrom P, et al. A study of the interaction of omeprazole and warfarin in anticoagulated patients. British Journal of Clinical Pharmacology. 1992;34(6):509-12.
Kwok CS, Arthur AK, Anibueze CI, Singh S, Cavallazzi R, Loke YK. Risk of Clostridium difficile Infection With Acid Suppressing Drugs and Antibiotics: Meta-Analysis. American Journal of Gastroenterology. 2012;107(7):1011-9.
Cheungpasitporn W, Thongprayoon C, Kittanamongkolchai W, Srivali N, Edmonds PJ, Ungprasert P, et al. Proton pump inhibitors linked to hypomagnesemia: a systematic review and meta-analysis of observational studies. Renal Failure. 2015;37(7):1237-41.
Ajmera AV, Shastri GS, Gajera MJ, Judge TA. Suboptimal Response to Ferrous Sulfate in Iron-Deficient Patients Taking Omeprazole. American Journal of Therapeutics. 2012;19(3):185-9.
Lam JR, Schneider JL, Zhao W, Corley DA. Proton Pump Inhibitor and Histamine 2 Receptor Antagonist Use and Vitamin B12 Deficiency. Journal of the American Medical Association. 2013;310(22):2435.
Ahn JS, Park SM, Eom CS, Kim S, Myung SK. Use of Proton Pump Inhibitor and Risk of Colorectal Cancer: A Meta-analysis of Observational Studies. Korean Journal of Family Medicine. 2012;33(5):272.
Oates JA, Wood AJJ, Feldman M, Burton ME. Histamine2 -Receptor Antagonists: Standard Therapy for Acid-Peptic Diseases. New England Journal of Medicine. 13 Aralık 1990;323(24):1672-80.
Meng R, Chen L, Zhang M, Cai W, Yin S, Fan Y, et al. Effectiveness and Safety of Histamine H2 Receptor Antagonists: An Umbrella Review of Meta‐Analyses. The Journal of Clinical Pharmacology. 2023;63(1):7-20.
Konturek SJ. New aspects of clinical pharmacology of antacids. Journal of Physiology and Pharmacology: An Official Journal of the Polish Physiological Society. 1993;44(3 Suppl 1):5-21.
Moss SF, Shah SC, Tan MC, El-Serag HB. Evolving Concepts in Helicobacter pylori Management. Gastroenterology. 2024;166(2):267-83.
Coşar AM, Özgür O Peptik ülserde Helicobacter pylori tedavisi Turkiye Klinikleri Journal Gastroenterohepatology-Special Topics 2013;6(1):49-55.
