Peptic Ulcer Disease

Dr Waseem Chisti
Fellow Emergency Medicine

Definition A circumscribed ulceration of the gastrointestinal mucosa occurring in areas exposed to acid and pepsin and most often caused by Helicobacter pylori infection.
(Uphold & Graham, 2003)

Peptic Ulcers: Gastric & Dudodenal .

Hospitalization rate is ~30 pts per 100. Pylori is sometimes associated with socioeconomic status and poor hygiene Lifetime prevalence is ~10%.000 cases .000 cases. PUD affects ~4.PUD Demographics  Higher prevalence in developing countries  H. Mortality rate has decreased dramatically in the past 20 years   In the US:     approximately 1 death per 100.5 million annually.

Comparing Duodenal and Gastric Ulcers .

Duodenal Ulcers         duodenal sites are 4x as common as gastric sites most common in middle age  peak 30-50 years Male to female ratio—4:1 Genetic link: 3x more common in 1st degree relatives more common in patients with blood group O associated with increased serum pepsinogen H. pylori infection common  up to 95% smoking is twice as common .

20% of patients with a gastric ulcer have a concomitant duodenal ulcer .associated with a three.Gastric Ulcers       common in late middle age  incidence increases with age Male to female ratio—2:1 More common in patients with blood group A Use of NSAIDs .to four-fold increase in risk of gastric ulcer Less related to H. pylori than duodenal ulcers – about 80% 10 .

The most important contributing factors are H pylori. bile acids.  Increased risk when older than 50 d/t decrease protection  When an imbalance occurs. PUD might develop. steroids. Important protective factors are mucus. NSAIDs. . hydrophobic layer. ethanol.Etiology     A peptic ulcer is a mucosal break. and pepsin. 3 mm or greater. mucosal blood flow. bicarbonate. prostaglandins. and stress. that can involve the stomach or duodenum. Additional aggressive factors include smoking. acid. and epithelial renewal. aspirin.

anorexia. or ―burning‖   Duodenal ulcers: occurs 1-3 hours after a meal and may awaken patient from sleep.  nausea. belching. &/or melena may also occur. ―aching‖. vomiting. hematemesis. vomiting. chest discomfort. bloating. Gastric ulcers: food may exacerbate the pain while vomiting relieves it. Pain is relieved by food.  Nausea. & weight loss more common with Gastric ulcers . dyspepsia.Subjective Data  Pain—‖gnawing‖. antacids. or vomiting.

Objective Data    Epigastric tenderness Guaic-positive stool resulting from occult blood loss Succussion splash resulting from scaring or edema due to partial or complete gastric outlet obstruction    A succussion splash describes the sound obtained by shaking an individual who has free fluid and air or gas in a hollow organ or body cavity. Done by gently shaking the abdomen by holding either side of the pelvis. A positive test occurs when a splashing noise is heard. . It is not valid if the pt has eaten or drunk fluid within the last three hours. Usually elicited to confirm intestinal or pyloric obstruction. either with or without a stethoscope.

Differential Diagnosis          Neoplasm of the stomach Pancreatitis Pancreatic cancer Diverticulitis Nonulcer dyspepsia (also called functional dyspepsia) Cholecystitis Gastritis GERD MI—not to be missed if having chest pain .

amylase. Upper GI Endoscopy: Any pt >50 yo with new onset of symptoms or those with alarm markings including anemia. and lipase. . weight loss. Pylori. Pylori can be diagnosed by urea breath test.  Preferred diagnostic test b/c its highly sensitive for dx of ulcers and allows for biopsy to rule out malignancy and rapid urease tests for testing for H. blood test. & rapid urease test on a biopsy sample. or GI bleeding. H. stool antigen assays.Diagnostic Plan     Stool for fecal occult blood Labs: CBC (R/O bleeding). liver function test.

 Proton Pump Inhibitor + clarithromycin and amoxicillin  Omeprazole (Prilosec): 20 mg PO bid for 14 d or Lansoprazole (Prevacid): 30 mg PO bid for 14 d or Rabeprazole (Aciphex): 20 mg PO bid for 14 d or Esomeprazole (Nexium): 40 mg PO qd for 14 d plus Clarithromycin (Biaxin): 500 mg PO bid for 14 and Amoxicillin (Amoxil): 1 g PO bid for 14 d  Can substitute Flagyl 500 mg PO bid for 14 d if allergic to PCN .Treatment Plan: H. Pylori  Medications: Triple therapy for 14 days is considered the treatment of choice.

In the setting of an active ulcer. Compliance! . continue qd proton pump inhibitor therapy for additional 2 weeks. Pylori. Once achieved reinfection rates are low. Goal: complete elimination of H.contd.

Pylori  Medications—treat with Proton Pump Inhibitors or H2 receptor antagonists to assist ulcer healing   H2: Tagament. Prevacid. Nexium.Treatment Plan: Not H. . Axid. Protonix. or Aciphex for 4-8 weeks. or Zantac for up to 8 weeks PPI: Prilosec. Pepcid.

Alcohol in moderation   Men under 65: 2 drinks/day Men over 65 and all women: 1 drink/day  Stress reduction .Lifestyle Changes      Discontinue NSAIDs and use Acetaminophen for pain control if possible. Acid suppression--Antacids Smoking cessation No dietary restrictions unless certain foods are associated with problems.

 Misoprostol (Cytotec) 100-200 mcg PO 4 times per day  Omeprazole (Prilosec) 20-40 mg PO every day  Lansoprazole (Prevacid) 15-30 mg PO every day .Prevention   Consider prophylactic therapy for the following patients:  Pts with NSAID-induced ulcers who require daily NSAID therapy  Pts older than 60 years  Pts with a history of PUD or a complication such as GI bleeding  Pts taking steroids or anticoagulants or patients with significant comorbid medical illnesses Prophylactic regimens that have been shown to dramatically reduce the risk of NSAID-induced gastric and duodenal ulcers include the use of a prostaglandin analogue or a proton pump inhibitor.

Gastric CA . Gastric outflow obstruction.Complications      Perforation & Penetration—into pancreas. liver and retroperitoneal space Peritonitis Bowel obstruction. & Pyloric stenosis Bleeding--occurs in 25% to 33% of cases and accounts for 25% of ulcer deaths.

which produces a hormone that stimulates the stomach to secrete digestive juices. . May be performed along with a vagotomy. or who develop complications:    Vagotomy .the opening into the duodenum and small intestine (pylorus) are enlarged.cutting the vagus nerve to interrupt messages sent from the brain to the stomach to reducing acid secretion.remove the lower part of the stomach (antrum). Antrectomy . enabling contents to pass more freely from the stomach.Surgery  People who do not respond to medication. Pyloroplasty . A vagotomy is usually done in conjunction with an antrectomy.

2-4 more weeks. If symptoms persist then refer to specialist for additional diagnostic testing.   H. . Patients who are controlled should cont.Evaluation/Follow-up/Referrals  H. Pylori Positive: retesting for tx efficacy   Urea breath test—no sooner than 4 weeks after therapy to avoid false negative results Stool antigen test—an 8 week interval must be allowed after therapy. Pylori Negative: evaluate symptoms after one month.

.Thank you.

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