Peptic Ulcer Disease

Upper GI

Clinicals - History

Fact Explanation
Abdominal pain Episodic gnawing or burning epigastric, postprandial and nocturnal pain due to GI mucosal injury caused by the evasion of H.pylori and/or aspirin/NSAIDS. Pain usually occurs 2-5 hours after meals or on an empty stomach. Pain is relieved by intake of food, antacids, or anti-secretory agents. Children present with poorly localized abdominal pain. In 30% of old patients with peptic ulcers, abdominal pain is usually absent. Postprandial epigastric pain is more likely to be relieved on ingestion of food or antacids in patients with duodenal ulcers than in those with gastric ulcers. Abdominal pain
Episodic gnawing or burning epigastric, postprandial and nocturnal pain due to GI mucosal injury caused by the evasion of H.pylori and/or aspirin/NSAIDS. Pain usually occurs 2-5 hours after meals or on an empty stomach. Pain is relieved by intake of food, antacids, or anti-secretory agents. Children present with poorly localized abdominal pain. In 30% of old patients with peptic ulcers, abdominal pain is usually absent. Postprandial epigastric pain is more likely to be relieved on ingestion of food or antacids in patients with duodenal ulcers than in those with gastric ulcers.
Persisting upper abdominal pain radiating to the back Suggests penetration. Persisting upper abdominal pain radiating to the back
Suggests penetration.
Sudden, rapidly spreading, severe upper abdominal pain Pain is worsened on movement and it suggests peptic ulcer perforation. Sudden, rapidly spreading, severe upper abdominal pain
Pain is worsened on movement and it suggests peptic ulcer perforation.
Vomiting Large amounts of vomit containing undigested food is usually associated with an obstruction due to pyloric stenosis or a gastric ulcer. Vomiting
Large amounts of vomit containing undigested food is usually associated with an obstruction due to pyloric stenosis or a gastric ulcer.
Anemia, hematemesis, melena, hematochezia or heme-positive stool Suggests bleeding from a possible gastric ulcer. Anemia, hematemesis, melena, hematochezia or heme-positive stool
Suggests bleeding from a possible gastric ulcer.
Weight loss / Loss of appetite Due to reduced appetite caused by fear of abdominal pain. Characteristic of gastric ulcers. Also suggests cancer. and gastric outlet obstruction. Weight loss / Loss of appetite
Due to reduced appetite caused by fear of abdominal pain. Characteristic of gastric ulcers. Also suggests cancer. and gastric outlet obstruction.
Cardiovascular disease therapy Patients taking medications such as low-dose aspirin (for the prevention of a cardiovascular event, such as myocardial infarction or thrombotic stroke), NSAIDS or any other antithrombotics for cardiovascular diseases are at an increased risk of developing GI injury and complications (peptic or bleeding ulcers). Cardiovascular disease therapy
Patients taking medications such as low-dose aspirin (for the prevention of a cardiovascular event, such as myocardial infarction or thrombotic stroke), NSAIDS or any other antithrombotics for cardiovascular diseases are at an increased risk of developing GI injury and complications (peptic or bleeding ulcers).
History of GI bleeding Patients who have had bleeding in the past from ulcers, experience recurrent bleeding within one year. History of GI bleeding
Patients who have had bleeding in the past from ulcers, experience recurrent bleeding within one year.
Family history Risk factor for PUD. Family history
Risk factor for PUD.
Medications Use of nonsteroidal anti-inflammatory drugs (NSAIDs) including aspirin, oral bisphosphonates, potassium chloride and immunosuppressive medications have been known to contribute to PUD. Medications
Use of nonsteroidal anti-inflammatory drugs (NSAIDs) including aspirin, oral bisphosphonates, potassium chloride and immunosuppressive medications have been known to contribute to PUD.
Personal history Question the patient of any personal history of peptic ulcers , cigarette smoking, excessive alcohol consumption, drug use, and emotional stress. These increase the risk of peptic ulcers. Personal history
Question the patient of any personal history of peptic ulcers , cigarette smoking, excessive alcohol consumption, drug use, and emotional stress. These increase the risk of peptic ulcers.
Syncope Indicates a possible duodenal perforation. Syncope
Indicates a possible duodenal perforation.

Clinicals - Examination

Fact Explanation
Hypotension, tachycardia, weak pulse, tachypenia, decreased pulse pressure, cool clammy skin, delayed capillary refill, slight anxiety Signs of shock indicating complicated PUD, which suggests hypovolemia/ anaemia due to significant upper GI blood loss and also a possible perforated duodenal ulcer. Hypotension, tachycardia, weak pulse, tachypenia, decreased pulse pressure, cool clammy skin, delayed capillary refill, slight anxiety
Signs of shock indicating complicated PUD, which suggests hypovolemia/ anaemia due to significant upper GI blood loss and also a possible perforated duodenal ulcer.
Fever, hypotension, oliguria Suggest sepsis and circulatory compromise caused by a perforated peptic ulcer. Fever, hypotension, oliguria
Suggest sepsis and circulatory compromise caused by a perforated peptic ulcer.
Generalized abdominal tenderness, rebound tenderness, board-like abdominal wall rigidity, hypoactive bowel sounds Clinical signs of peritonitis suggesting a perforated peptic ulcer. These may be masked during the physical examination in older patients with a perforated peptic ulcer and also in those taking steroids, immunosuppressants, or narcotic analgesics. Generalized abdominal tenderness, rebound tenderness, board-like abdominal wall rigidity, hypoactive bowel sounds
Clinical signs of peritonitis suggesting a perforated peptic ulcer. These may be masked during the physical examination in older patients with a perforated peptic ulcer and also in those taking steroids, immunosuppressants, or narcotic analgesics.
Dehydration; a tympanitic epigastric mass with visible gastric peristalsis In addition to symptoms suggesting obstruction, these signs maybe witnessed in a patient presenting with gastric outlet obstruction (pyloric stenosis) whose underlying cause is peptic ulcer disease in 5-8% of patients. Dehydration; a tympanitic epigastric mass with visible gastric peristalsis
In addition to symptoms suggesting obstruction, these signs maybe witnessed in a patient presenting with gastric outlet obstruction (pyloric stenosis) whose underlying cause is peptic ulcer disease in 5-8% of patients.

Investigations - Diagnosis

Fact Explanation
Full Blood Count Insignificant but done to exclude any other abnormalities and is also reassuring. Full Blood Count
Insignificant but done to exclude any other abnormalities and is also reassuring.
Helicobacter pylori testing Regardless of whether a patient is taking aspirin and all those with an ulcer should be tested for H. pylori infection to determine the best treatment. *Serologic ELISA: Useful only for initial H.pylori testing (sensitivity 85%; specificity 79%) and cannot be used for the confirmation of eradication. *Urea breath test: Best test that can detect an active H.pylori infection (sensitivity 95%-100% , specificity 94%-99% ). This is also the test of choice to confirm eradication but PPI therapy should be stopped for 2 weeks before the test. *Stool antigen test: An inconvenient but an accurate H.pylori test that can be done (sensitivity 91%-98%; specificity 94%-99%) and can also be used to confirm eradication. Helicobacter pylori testing
Regardless of whether a patient is taking aspirin and all those with an ulcer should be tested for H. pylori infection to determine the best treatment. *Serologic ELISA: Useful only for initial H.pylori testing (sensitivity 85%; specificity 79%) and cannot be used for the confirmation of eradication. *Urea breath test: Best test that can detect an active H.pylori infection (sensitivity 95%-100% , specificity 94%-99% ). This is also the test of choice to confirm eradication but PPI therapy should be stopped for 2 weeks before the test. *Stool antigen test: An inconvenient but an accurate H.pylori test that can be done (sensitivity 91%-98%; specificity 94%-99%) and can also be used to confirm eradication.
Esophagogastroduodenoscopy (EGD) Prompt EGD is indicated for patients with 'alarm symptoms' (anemia, hematemesis, melena, or heme-positive stool; vomiting, anorexia or weight loss; persisting upper abdominal pain radiating to the back or severe, spreading upper abdominal pain) those whose symptoms do not respond to medications; and those older than 55 years. EGD helps in the accurate diagnosis and differential diagnosis of PUD and ulcer complications (e.g. biopsy of gastric lesions can be done to exclude malignancy or to obtain tissue for an H. pylori diagnostic test). An EGD is the most important step of management in a patient with an acute upper GI bleeding to establish the cause of bleeding (60% is due to peptic ulcer disease) and also to hemostasis during the endoscopy to control the source of bleeding. Biopsies should ideally be taken in a systematic fashion, taking samples of antrum, corpus and going distally down the upper GI tract. Esophagogastroduodenoscopy (EGD)
Prompt EGD is indicated for patients with 'alarm symptoms' (anemia, hematemesis, melena, or heme-positive stool; vomiting, anorexia or weight loss; persisting upper abdominal pain radiating to the back or severe, spreading upper abdominal pain) those whose symptoms do not respond to medications; and those older than 55 years. EGD helps in the accurate diagnosis and differential diagnosis of PUD and ulcer complications (e.g. biopsy of gastric lesions can be done to exclude malignancy or to obtain tissue for an H. pylori diagnostic test). An EGD is the most important step of management in a patient with an acute upper GI bleeding to establish the cause of bleeding (60% is due to peptic ulcer disease) and also to hemostasis during the endoscopy to control the source of bleeding. Biopsies should ideally be taken in a systematic fashion, taking samples of antrum, corpus and going distally down the upper GI tract.
Barium or Gastrografin contrast radiography (double-contrast hypotonic duodenography) Indicated when endoscopy is unsuitable or not feasible, or if complications such as gastric outlet obstruction is suspected. Barium or Gastrografin contrast radiography (double-contrast hypotonic duodenography)
Indicated when endoscopy is unsuitable or not feasible, or if complications such as gastric outlet obstruction is suspected.

Investigations - Management

Fact Explanation
Post-treatment urea breath test or endoscopy Follow-up testing is very important because of the risk of ulcer recurrence and the potential for malignancy caused by H. pylori infection. These follow-up tests are indicated in collaboration with a gastroenterologist for patients having a history of ulcer complications, gastric mucosa-associated lymphoid tissue (MALT), or early gastric cancer to ensure successful H.pylori eradication. Post-treatment urea breath test or endoscopy
Follow-up testing is very important because of the risk of ulcer recurrence and the potential for malignancy caused by H. pylori infection. These follow-up tests are indicated in collaboration with a gastroenterologist for patients having a history of ulcer complications, gastric mucosa-associated lymphoid tissue (MALT), or early gastric cancer to ensure successful H.pylori eradication.
Stool antigen test This testing is routinely indicated for patients with persistent symptoms following eradication therapy. Stool antigen test
This testing is routinely indicated for patients with persistent symptoms following eradication therapy.

Management - Supportive

Fact Explanation
Patient education Counsel patients about the importance of completing the drug regimen needed for effective eradication. Also make them aware about the risks of dyspepsia leading to recurrence and slow healing. Advice them to discontinue the use of NSAIDs, cigarette smoking, alcohol, and illicit drug use. NSAIDs delay ulcer healing and hence regardless of the underlying etiology of the ulcer NSAID therapy should be discontinued. Smoking has also found to have a synergistic relationship with H. pylori and hence it should be stopped. Patient education
Counsel patients about the importance of completing the drug regimen needed for effective eradication. Also make them aware about the risks of dyspepsia leading to recurrence and slow healing. Advice them to discontinue the use of NSAIDs, cigarette smoking, alcohol, and illicit drug use. NSAIDs delay ulcer healing and hence regardless of the underlying etiology of the ulcer NSAID therapy should be discontinued. Smoking has also found to have a synergistic relationship with H. pylori and hence it should be stopped.

Management - Specific

Fact Explanation
Initial resuscitation Initial management of a perforated duodenal/gastric ulcer includes of giving the patient large-volume crystalloids; nasogastric suction; and administration of intravenous broad-spectrum antibiotics against gram-negative rods, anaerobes, and oral flora. Followed by a laparotomy and the placement of an omental patch whereas for a perforated gastric ulcer an omental patch, wedge resection of the ulcer, or a partial gastrectomy and reanastomosis may be performed. Any coexisting H.pylori infection must be eradicated to prevent any future recurrences and complications needing further medical/surgical treatment. Initial resuscitation
Initial management of a perforated duodenal/gastric ulcer includes of giving the patient large-volume crystalloids; nasogastric suction; and administration of intravenous broad-spectrum antibiotics against gram-negative rods, anaerobes, and oral flora. Followed by a laparotomy and the placement of an omental patch whereas for a perforated gastric ulcer an omental patch, wedge resection of the ulcer, or a partial gastrectomy and reanastomosis may be performed. Any coexisting H.pylori infection must be eradicated to prevent any future recurrences and complications needing further medical/surgical treatment.
Eradication of Helicobacter pylori Standard treatment for H.pylori positive ulcers: H.pylori eradication + PPI (has the most potent acid inhibition plus cures the infection). Treatment duration is 10 to 14 days and following are the course options:
'Triple therapy' : *Omeprazole (Prilosec) (20 mg twice daily) OR lansoprazole (Prevacid) (30 mg twice daily), plus amoxicillin (1 g twice daily) OR metronidazole (Flagyl) (500 mg twice daily) (if allergic to penicillin)
plus clarithromycin (Biaxin) (500 mg twice daily).
*Ranitidine bismuth citrate (Tritec) (400 mg twice daily) plus clarithromycin (500 mg twice daily) OR metronidazole (500 mg twice daily) plus tetracycline (500 mg twice daily) OR amoxicillin (1 g twice daily).
*Levofloxacin (Levaquin) (500 mg daily)
plus amoxicillin (1 g twice daily)
plus pantoprazole (Protonix) (40 mg twice daily). (Eradication rates have been reported to be 80%-90% or higher).
'Quadruple therapy': Indicated for patients who did not respond to triple therapy. *Bismuth subsalicylate (Pepto-Bismol) (525 mg (two tablets) four times daily)
plus metronidazole (250 mg four times daily) plus tetracycline (500 mg four times daily) plus H2 blocker (for 28 days) OR proton pump inhibitor (for 14 days). Patients should be referred to a gastroenterologist if treatment fails to respond for a second time.
Eradication of Helicobacter pylori
Standard treatment for H.pylori positive ulcers: H.pylori eradication + PPI (has the most potent acid inhibition plus cures the infection). Treatment duration is 10 to 14 days and following are the course options:
'Triple therapy' : *Omeprazole (Prilosec) (20 mg twice daily) OR lansoprazole (Prevacid) (30 mg twice daily), plus amoxicillin (1 g twice daily) OR metronidazole (Flagyl) (500 mg twice daily) (if allergic to penicillin)
plus clarithromycin (Biaxin) (500 mg twice daily).
*Ranitidine bismuth citrate (Tritec) (400 mg twice daily) plus clarithromycin (500 mg twice daily) OR metronidazole (500 mg twice daily) plus tetracycline (500 mg twice daily) OR amoxicillin (1 g twice daily).
*Levofloxacin (Levaquin) (500 mg daily)
plus amoxicillin (1 g twice daily)
plus pantoprazole (Protonix) (40 mg twice daily). (Eradication rates have been reported to be 80%-90% or higher).
'Quadruple therapy': Indicated for patients who did not respond to triple therapy. *Bismuth subsalicylate (Pepto-Bismol) (525 mg (two tablets) four times daily)
plus metronidazole (250 mg four times daily) plus tetracycline (500 mg four times daily) plus H2 blocker (for 28 days) OR proton pump inhibitor (for 14 days). Patients should be referred to a gastroenterologist if treatment fails to respond for a second time.
Proton pump inhibitors (PPI) Standard treatment for H.pylori -positive and -negative ulcers; prevention of NSAID/aspirin-induced ulcers and intravenous administration for bleeding ulcers. PPIs have the most potent acid inhibition. Treatment duration for duodenal ulcer is 4 weeks and 8 weeks for gastric ulcer with 80%-100% healing.
*Omeprazole (20 mg daily)
*Lansoprazole (15 mg daily)
*Rabeprazole (Aciphex) (20 mg daily)
*Pantoprazole (40 mg daily)
Proton pump inhibitors (PPI)
Standard treatment for H.pylori -positive and -negative ulcers; prevention of NSAID/aspirin-induced ulcers and intravenous administration for bleeding ulcers. PPIs have the most potent acid inhibition. Treatment duration for duodenal ulcer is 4 weeks and 8 weeks for gastric ulcer with 80%-100% healing.
*Omeprazole (20 mg daily)
*Lansoprazole (15 mg daily)
*Rabeprazole (Aciphex) (20 mg daily)
*Pantoprazole (40 mg daily)
Histamine H2 blockers Used for the treatment of H.pylori -negative ulcers. Healing of duodenal ulcers has been seen 70%-80% after four weeks and 87%-94% after eight weeks.
*Ranitidine (Zantac) 150 mg two times daily OR 300 mg at night.
*Famotidine (Pepcid) 20 mg two times daily OR 40 mg at night.
*Cimetidine (Tagamet) 400 mg two times daily OR 800 mg at night.
Histamine H2 blockers
Used for the treatment of H.pylori -negative ulcers. Healing of duodenal ulcers has been seen 70%-80% after four weeks and 87%-94% after eight weeks.
*Ranitidine (Zantac) 150 mg two times daily OR 300 mg at night.
*Famotidine (Pepcid) 20 mg two times daily OR 40 mg at night.
*Cimetidine (Tagamet) 400 mg two times daily OR 800 mg at night.
Sucralfate (Carafate) (1 g four times daily) Treatment duration is 4 weeks and its effectiveness is similar to H2 blockers. Sucralfate (Carafate)
(1 g four times daily) Treatment duration is 4 weeks and its effectiveness is similar to H2 blockers.
Prostaglandin analogs (Misoprostol) Used for the treatment of H.pylori -negative ulcers and for the prevention of NSAID/aspirin-induced ulcers. Prostaglandin analogs (Misoprostol)
Used for the treatment of H.pylori -negative ulcers and for the prevention of NSAID/aspirin-induced ulcers.
Phosphatidylcholine-aspirin (PL2200) Used for the treatment of H.pylori -negative ulcers and for the prevention of aspirin-induced ulcers. Phosphatidylcholine-aspirin (PL2200)
Used for the treatment of H.pylori -negative ulcers and for the prevention of aspirin-induced ulcers.
Surgery Rarely needed. But surgery is highly indicated when there is development of complications from PUD (commonly GI bleeding), failure of initial endoscopic hemostasis attempts , poor response to medical therapy or a need for multiple rounds of medical therapy for ulcers, and high-risk factors (eg, history of PUD, dependence upon steroid or NSAID therapy).
*Duodenal ulcer: truncal vagotomy, selective vagotomy, highly selective vagotomy, partial gastrectomy.
*Gastric ulcer: partial gastrectomy with gastroduodenal or gastrojejunal anastomosis (in bleeding gastric ulcers).
Surgery
Rarely needed. But surgery is highly indicated when there is development of complications from PUD (commonly GI bleeding), failure of initial endoscopic hemostasis attempts , poor response to medical therapy or a need for multiple rounds of medical therapy for ulcers, and high-risk factors (eg, history of PUD, dependence upon steroid or NSAID therapy).
*Duodenal ulcer: truncal vagotomy, selective vagotomy, highly selective vagotomy, partial gastrectomy.
*Gastric ulcer: partial gastrectomy with gastroduodenal or gastrojejunal anastomosis (in bleeding gastric ulcers).

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