Tularemia

Disease Description (Causes and Symptoms)

• Definition and pathophysiology: A gastric ulcer is an ulcer in which damage to the gastric mucosa extends beyond the mucosal layer and invades the muscular layer. It occurs when the balance between normal mucosal defenses (mucus, bicarbonate, blood flow, cell regeneration, etc.) and gastric acid and pepsin is disrupted.
• Main causes: Helicobacter pylori infection (most common), use of nonsteroidal anti-inflammatory drugs (NSAIDs) (mucosal damage caused by inhibition of prostaglandins), smoking, severe stress, excessive gastric acid secretion, etc.
• Main symptoms: Burning sensation/pain in the epigastric area (upper abdomen) (mainly within 30 minutes to 3 hours after meals), heartburn, indigestion, nausea and vomiting, loss of appetite and weight loss. If bleeding occurs, hematemesis, black stools (melena), and anemia may develop. In the event of perforation, acute abdominal pain may occur; if gastric outlet obstruction occurs, persistent vomiting may develop.

Treatment Methods

• Medication treatment
  • Gastric acid secretion inhibitors: Proton pump inhibitors (PPIs, e.g., omeprazole and esomeprazole) for 4–8 weeks (the usual healing period). PPI use is also recommended in NSAID-related cases.
  • Mucosal protectants: May be used in combination when necessary.
• Helicobacter pylori (H. pylori) treatment
  • When eradication therapy is recommended: PPI + 2 or more types of antibiotics (standard triple therapy: PPI + amoxicillin + clarithromycin, etc.; however, regional antibiotic resistance should be considered). When resistance rates are high, alternative therapies such as bismuth quadruple therapy (PPI + bismuth + tetracycline + metronidazole) or concomitant therapy are recommended.
  • Treatment period: Usually 10–14 days (according to regional guidelines).
  • Confirmation of eradication: A urea breath test or stool antigen test is recommended after completion of treatment (discontinue PPI for at least 2 weeks and antibiotics/bismuth for at least 4 weeks before testing).
• Treatment of complications such as bleeding, perforation, ongoing bleeding, or obstruction
  • Bleeding: Emergency endoscopic hemostasis (clipping, injection, thermal coagulation, etc.), with transfusion and hemodynamic stabilization when necessary.
  • Perforation: Initial laparoscopic/surgical treatment may be considered (emergency surgery if peritonitis or systemic abnormalities are present).
  • Gastric outlet obstruction: Endoscopic dilation or surgical treatment.
• Lifestyle management and precautions
  • Discontinue drugs that damage the gastric mucosa, such as NSAIDs and aspirin, or consult a doctor. If chronic NSAID use is necessary, consider combining it with a gastroprotective agent (PPI or misoprostol, etc.).
  • Stop smoking (smoking increases the risk of recurrence and complications), and limit excessive alcohol consumption and irritating (spicy/salty) foods.
  • Manage stress and maintain adequate nutritional intake.
• Follow-up testing (to assess the possibility of malignancy)
  • If there are findings suspicious for a malignant tumor after treatment or risk factors are present, repeat endoscopy and biopsy may be considered. (The timing of follow-up endoscopy after treatment (e.g., 2 months, 6 months, 12 months, etc.) is determined according to clinical findings and risk level.)

Checklist Before an Outpatient Visit (Including Example Questions)

• Items to bring
  • A list of all medications currently being taken (including prescription drugs, over-the-counter drugs, and supplements)
  • Whether anticoagulants or antiplatelet agents are being taken (e.g., warfarin, aspirin, clopidogrel, etc.)
  • Allergy history and history of previous adverse drug reactions
  • Results of recently performed tests (H. pylori tests, blood tests, previous endoscopy findings, etc.)
  • Record of symptom changes: time of symptom onset, nature and timing of pain (before or after meals), bleeding symptoms (hematemesis and melena), weight changes, frequency of vomiting, etc.
  • Lifestyle information: smoking, alcohol consumption, long-term NSAID use, and stress level
• Items to submit to or prepare in advance for the healthcare provider during the outpatient visit
  • Medication list and dosing times, symptom diary (if available)
• Examples of precautions before the visit
  • If testing (such as a urea breath test) is scheduled, PPI must be discontinued 2 weeks before the test, and antibiotics and bismuth must be discontinued 4 weeks before the test (follow the doctor's instructions).

Examples of General Questions to Ask the Doctor

• What are the main side effects of this medication (PPI/antibiotics, etc.)? What problems could occur with long-term use?
• How can I confirm whether eradication therapy was successful? When is the best time to undergo the test?
• How long do I need to take the medication? Is it safe to stop taking the PPI?
• What lifestyle changes should I make to reduce the risk of recurrence?
• If I have a high risk of complications such as bleeding or perforation, what symptoms should I recognize early?

Examples of Disease-Specific Questions

• Regarding eradication therapy: "What combination of medications do you recommend for eradication therapy? What is the recommended treatment considering the local antibiotic resistance rate?"
• Regarding follow-up testing (excluding malignancy): "When and at what intervals should I undergo endoscopy and biopsy after treatment to rule out malignancy in my ulcer? Are there any additional endoscopic findings I should pay attention to?"