Clinical Practice Guidelines for Peptic Ulcer Disease

1) Drug Treatment of Gastroduadenal Ulcer associated with Helicobacter Pylori (HP)

a) Seven day regimen: may be taken up to 10-14 days

Options Drug Regimen Eradication Rate

- Omeprasol (Losek, Omez) from other

1 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 87 – 91%
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.
- Omeprasol (Losek, Omez) from other

2 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. 80 – 90%
- 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.
 - Omeprasol (Losek and analogues) 20

3 mg bid (in the 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 77 – 83%
the end of the meal
- Metronidazole (Trikhopole and other
analogues) 500 mg bid at the end of the
meal.
- Pylorid (Ranitidin Bismuth Citrate) 400

4 mg bid at the end of the meal

- Klarythromycin (Klacide) 250 mg/bid
78 – 83%
or tetracycline 500 mg four times a day or
Amoxicillin 1000 mg/bid
- Metronidazole (Trikhopole and other
analogues) 500 mg bid at the end of the
meal.

5 - 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 in tetracycline regimen 88 –
(Ventrisol, Denol and other analogues) 240 90%

mg/bid 30 minutes before the meal in amoxicillin 80 – 86%

(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 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

b) Two – week regimen

Option Drug Regimen Eradication Rate

- Ranitidin (Zantak and other analogies) 150

1 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; 80%
 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
 - Potassium salt of bismuth citrate – gastrostat

2 120 mg/qid before the meal

 Metronidazole 250 mg/qid after meal
75%
 Tetracyclin hydrochloride 250
mg/qid after meals

Note:
 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.

2) Refractory ulcer.
The most common causes of refractory and recurrent ulcer include:
 ineffective eradication therapy;
 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 of therapy 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.

3) Treatment of Ulcer caused by NSAIDs

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.

3) Drug Treatment of Gastroduadenal Ulcer not associated with Helicobacter Pylori (HP)

To exclude or reduce smoking and alcohol use as well as NSAID use, one of the following drug
combinations and regimens is used:
- Ranitidin (Zantak and other analogues) 300 mg a day, single dose at 7–8 P.M. and
antacid (Maaloks, Remagel, Gastrin gel, etc.) as symptomatic medication
- Famotidin (Gastrosidin, Kvamatel, Ulfamid) 40 mg a day at 7–8 P.M. and antacid
(Maaloks,Remagel, Gastrin gel, etc.) as symptomatic medication
- 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.
 ALGORITHM: MANAGEMENT OF NON-VARICEAL UPPER GASTEROINTESTINAL
BLEEDING

Clinical Practice Guidelines for Alcohol Liver Disease (ALD)

1) The most important aspect of treatment in ALD is the immediate and total abstinence
from alcohol. It is also critical that the patient’s nutritional intake is adjusted to maintain a
high caloric, high protein diet.
This does not need to be accomplished within the confines of a hospital, although efforts to
enroll these patients in a detoxification program are clearly justified.
2) Hospitalization may be necessary for those patients who have extrahepatic complications
or those with risks factors associated with acute liver-related mortality. Drugs may be used to
treat the symptoms of withdrawal. Proteins and vitamin dietary supplements are prescribed.
Vitamin B and K are administered. Potassium, magnesium and zinc are administered to those
patients with decompensated liver disease.
3) Corticosteroids are prescribed for severely ill patients. This group of patients, with a high
risk of mortality, have been found to have high levels of circulating proinflammatory
cytokines. These are blocked by steroids, which have an anti-inflammatory effect.
Pentoxifylline prevents worsening of renal function in patients with severe alcoholic
hepatitis.
4) Orthotopic liver transplantation improves survival rates in decompensated liver cirrhosis.
Currently, alcoholic liver disease is the single most common indication for transplantation in
adults in the United States. However, considering the scarcity of donors and the financial
expenditure, most transplant centers require a documented period of abstinence from alcohol
(usually 6-12 months).
Clinical Practice Guidelines for Hepatitis A

Guidelines for epidemic measures

1) Determination of mode of transmission, whether person-to-person or by common vector
(vehicle).
2) Identification of the population exposed to increased risk of infection. Elimination of
common sources of infection.
3) Improvement of sanitary and hygienic practices to eliminate faecal contamination of food
and water.
4) Hepatitis A vaccination has been shown to be effective in controlling outbreaks of
infection in communities that have high or intermediate rates of infection, provided a
sufficient percent of the target population is reached.30, 45
5) Passive immunization provides temporary protection, but it is not effective in controlling
HAV on a community level.

Treatment
1) As no specific treatment exists for hepatitis A, prevention is the most effective approach
against the disease.
2) Therapy should be supportive and aimed at maintaining adequate nutritional balance (1
g/kg protein, 30-35 cal/kg). There is no good evidence that restriction of fats has any
beneficial effect on the course of the disease. Eggs, milk and butter may actually help
provide a correct caloric intake. Alcoholic beverages should not be consumed during
acute hepatitis because of the direct hepatotoxic effect of alcohol. On the other hand, a
modest consumption of alcohol during convalescence does not seem to be harmful.
Hospitalization is usually not required.
3) Patients who are taking oral contraceptives do not need to discontinue their use during the
course of the disease.
4) Referral to a liver transplant centre is appropriate for patients with fulminant hepatitis A,
although the identification of patients requiring liver transplantation is difficult. A good
proportion of patients (60%) with grade 4 encephalopathy will still survive without
transplantation. Temporary auxiliary liver transplantation for subacute liver failure may
 be a way to promote native liver regeneration.

Clinical Practice Guidelines for Hepatitis B

Currently there are no treatments available for acute hepatitis B. Symptomatic treatment
of nausea, anorexia, vomiting and other symptoms may be indicated. There are 2 main classes of
treatment:
- Antiviral: aimed at suppressing or destroying HBV by interfering with viral replication
- Immune modulators: aimed at helping the human immune system to mount a defense
against the virus
Currently, chronic hepatitis B is treated with interferons. The only approved ones are interferons-
α-2a and interferon-α-2b.
Guidelines for Epidemic measures

1) When two or more cases occur in association with some common exposure, a search for
additional cases should be conducted.

2) Introduction of strict aseptic techniques. If a plasma derivative like antihaemophilic

factor, fibrinogen, pooled plasma or thrombin is implicated.

3) Tracing of all recipients of the same lot in search for additional cases.

4) Relaxation of sterilization precaution and emergency use of unscreened blood for

transfusion may result in increased number of cases.

Clinical Practice Guidelines for Hepatitis C

- The rationales for treatment of chronic hepatitis C are to reduce inflammation, to prevent
progression to fibrosis, cirrhosis and HCC through the eradication of the virus in chronically
infected patients and to decrease infectivity and control the spread of the disease.

- Interferon has been shown to normalize liver tests, improve hepatic inflammation and
reduce viral replication in chronic hepatitis C and is considered the standard therapy for
chronic hepatitis C.
 - Combination therapy with pegylated interferon and ribavirin for 24 or 48 weeks should
be the treatment of choice for patients who relapse after interferon treatment. A relapse rate
of less than 20% occurs in relapse patients treated with combination therapy for a year.

Clinical Practice Guidelines for Hepatitis D

- Currently there is no effective antiviral therapy available for acute or chronic type D
hepatitis.
- For infected patients, massive doses of α-interferon (9 million units, 3 times a week for
12 months or 5 million units for up to 12 months) have yielded remissions but most patients
remained positive for HDV RNA despite the improved disease conditions.
- The effect of interferon is considered to be most likely an indirect one, possibly via an
effect on the helper hepa DNA virus and/or the immune response to the infections.

Clinical Practice Guidelines for Hepatitis E

- As no specific therapy is capable of altering the course of acute hepatitis E infection,
prevention is the most effective approach against the disease.
- As with hepatitis A, hepatitis E patients generally do not require hospitalization.
- Admission is required for fulminant hepatitis and should be considered for infected
pregnant women

Guidelines for epidemic measures

1) Determination of mode of transmission.
2) Identification of the population exposed to increased risk of infection.
3) Elimination of common source of infection.
4) Improvement of sanitary and hygienic practices to eliminate faecal contamination of food
and water.