PEPTIC ULCER DISEASE

A peptic ulcer is a defect in the gastric or duodenal mucosa that extends through the muscularis mucosa into the deeper layers of
the wall.
Causes:
- H. Pylori
- NSAIDS
- Stress
Symptoms:
- Approximately 70 percent of peptic ulcers are asymptomatic
- Epigastric pain
- Pain can radiate to the back
- The "classic" pain of duodenal ulcers occurs two to five hours after a meal when acid is secreted in the absence of a food
buffer, and at night (between about 11 PM and 2 AM) when the circadian pattern of acid secretion is maximal
- Patients may have associated symptoms of bloating, abdominal fullness, nausea, and early satiety that may be provoked by
eating
- Bleeding
Laboratory findings
- Most patients with uncomplicated peptic ulcers have a normal complete blood count. Patients may have iron deficiency
anemia due to recurrent gastrointestinal blood loss. Patients with acute gastrointestinal perforation may have leukocytosis.
Ddx:
The differential diagnosis of peptic ulcer disease consists of other causes of dyspepsia and includes drug-induced dyspepsia,
biliary disease, gastric malignancy, and less commonly, chronic pancreatitis. These conditions can be excluded from peptic
ulcer disease by upper endoscopy.
Diagnosis:
1. Upper endoscopy — Endoscopy is the most accurate diagnostic test for peptic ulcer disease.
Indications for ulcer biopsy
Malignant appearing ulcers — All ulcers with malignant features should be biopsied. Endoscopic features that suggest that
an ulcer may be malignant include:
●An ulcerated mass protruding into the lumen
●Folds surrounding the ulcer crater that are nodular, clubbed, fused, or stop short of the ulcer margin
●Overhanging, irregular, or thickened ulcer margins
**Duodenal biopsy
Routine biopsy of benign-appearing duodenal ulcers is not recommended as they are unlikely to be malignant. In areas with
high gastric cancer incidence, gastric ulcers should be biopsied. The decision to biopsy benign-appearing gastric ulcers in
areas of low gastric cancer incidence is controversial.
2. Test for H. pylori infection
Stool culture
Urea breath test

Treatment
Lifestyle changes may include:
• Not eating certain foods. Avoid any foods that make your symptoms worse.
• Quitting smoking. Smoking can keep your ulcer from healing. It is also linked to ulcers coming back after treatment.
• Limiting alcohol and caffeine. They can make your symptoms worse.
• Not using NSAIDs (non-steroidal anti-inflammatory medicines). These include aspirin and ibuprofen.
Other:
- Triple therapy: claritho, amoxo, PPI
- Surgery
o Surgical management is reserved for peptic ulcer disease that is refractory to medical management, for suspicion of
a malignancy within an ulcer, or for the management of complications of peptic ulcer disease (ie, bleeding,
perforation, obstruction).
o Definitive acid-reducing procedures include highly selective vagotomy, truncal vagotomy with gastric drainage, and
distal gastrectomy with reconstruction. The choice of procedure depends upon the clinical circumstances
 ▪ Elective: Vagotomy reduces the risk of recurrent ulceration while minimizing postoperative complications
and long-term sequelae.
• Do laparoscopic better than open
▪ Duodenal bleeding: truncal vagotomy and pyloroplasty
▪ Perforated duodenal ulcers: can generally be treated by closure with a piece of omentum (Graham patch)
or, for perforated ulcers close to the pylorus, by truncal vagotomy with pyloroplasty
▪ Resection: The extent of gastric resection for gastric ulcer, which may harbor malignancy, depends upon
the size and location of the ulcer. For uncomplicated or complicated gastric ulcer, we suggest partial
gastrectomy and reconstruction rather than simple ulcer excision in good-risk surgical candidates (Grade
2C). For patients with significant medical comorbidities, alternatives include ulcer excision for bleeding or
patch closure for perforation, possibly combined with vagotomy and gastric drainage.
o

Complications
- Bleeding
- Perforation
- Obstruction
o Ulcers that are found where the duodenum joins the stomach can cause swelling and scarring. This can narrow or
even block the opening to the duodenum. Food can’t leave your stomach and go into your small intestine. This
causes vomiting. You can’t eat properly.
Choledocholithiasis
- Gallstones within the common bile duct
- Cause:
o Primary choledocholithiasis (ie, formation of stones within the common bile duct) typically occurs in the setting of
bile stasis (eg, patients with cystic fibrosis)
▪ Older adults with large bile ducts and periampullary diverticular are also at elevated risk for the formation
of primary bile duct stones
▪ Patients with recurrent or persistent infection involving the biliary system frequently form bile duct stones,
a phenomenon seen most commonly in populations from East Asia.
▪ ischemia due to hepatic artery injury, which may occur post-liver transplant.
o Secondary choledocholithiasis results from the passage of gallstones from the gallbladder into the common bile
duct. In Western countries, most cases of choledocholithiasis are secondary to gallbladder stones.
- Sx:
o Biliary type pain
▪ right upper quadrant or epigastric pain, nausea, and vomiting
▪ The pain is often more prolonged than is seen with typical biliary colic (which typically resolves within six
hours).
o
- Labs:
o Serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST) concentrations are typically elevated
early in the course of biliary obstruction. Later, liver tests are typically elevated in a cholestatic pattern, with
increases in serum bilirubin, alkaline phosphatase, and gamma-glutamyl transpeptidase (GGT) exceeding the
elevations in serum ALT and AST.
- Complications:
o Complications of choledocholithiasis include acute pancreatitis and acute cholangitis. Patients with acute
pancreatitis typically have elevated serum pancreatic enzyme levels, and patients with acute cholangitis are often
febrile with a leukocytosis. Rarely, patients with long-standing biliary obstruction develop secondary biliary
cirrhosis.
 ▪ Patients with acute cholangitis often present with Charcot's triad (fever, right upper quadrant pain, and
jaundice) and leukocytosis
▪ In severe cases, bacteremia and sepsis may lead to hypotension and altered mental status (Reynolds'
pentad).
o