Peptic ulcer disease: Difference between revisions
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**[[H. pylori]] found in 30-40% of U.S. population | **[[H. pylori]] found in 30-40% of U.S. population | ||
**[[NSAIDs]] inhibit prostaglandin synthesis (decreases mucus and bicarb production) | **[[NSAIDs]] inhibit prostaglandin synthesis (decreases mucus and bicarb production) | ||
*Perforation most commonly occurs in anterior wall of duodenum. | |||
==Clinical Features== | ==Clinical Features== | ||
===Non-Perforated=== | |||
*Burning [[epigastric pain]] | *Burning [[epigastric pain]] | ||
**May awaken patient at night (gastric contents empty) | **May awaken patient at night (gastric contents empty) | ||
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*The following symptoms are NOT associated with PUD: | *The following symptoms are NOT associated with PUD: | ||
**Postprandial pain, food intolerance, nausea, retrosternal pain, belching | **Postprandial pain, food intolerance, nausea, retrosternal pain, belching | ||
===Perforated=== | |||
*Abrupt onset of severe epigastric pain | |||
*Patients may not have history of ulcer-like symptoms | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
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*Hemorrhage | *Hemorrhage | ||
**[[Upper GI Bleeding]] | **[[Upper GI Bleeding]] | ||
*Perforation | *Perforation (see above) | ||
*[[SBO|Obstruction]] | *[[SBO|Obstruction]] | ||
*Occurs due to: | |||
**Scarring of gastric outlet | |||
**Edema due to active ulcer | |||
==See Also== | ==See Also== | ||
Revision as of 18:44, 28 November 2019
Background
- Recurrent ulcerations in the stomach and proximal duodenum
- Defect in the gastric or duodenal wall that extends through the muscularis mucosa into the deeper layers of the wall[1]
- Majority of cases related to H. pylori or NSAID use
- Perforation most commonly occurs in anterior wall of duodenum.
Clinical Features
Non-Perforated
- Burning epigastric pain
- May awaken patient at night (gastric contents empty)
- Abrupt onset of severe pain may indicate perforation
- Abrupt onset of back pain may indicate penetration into the pancreas
- The following symptoms are NOT associated with PUD:
- Postprandial pain, food intolerance, nausea, retrosternal pain, belching
Perforated
- Abrupt onset of severe epigastric pain
- Patients may not have history of ulcer-like symptoms
Differential Diagnosis
Epigastric Pain
- Gastroesophageal reflux disease (GERD)
- Peptic ulcer disease with or without perforation
- Gastritis
- Pancreatitis
- Gallbladder disease
- Myocardial Ischemia
- Splenic Infarctionenlargement/rupture/aneurysm
- Pericarditis/Myocarditis
- Aortic dissection
- Hepatitis
- Pyelonephritis
- Pneumonia
- Pyogenic liver abscess
- Fitz-Hugh-Curtis Syndrome
- Hepatomegaly due to CHF
- Bowel obstruction
- SMA syndrome
- Pulmonary embolism
- Bezoar
- Ingested foreign body
Upper gastrointestinal bleeding
- Peptic ulcer disease (most common cause)
- Gastritis/esophagitis
- Gastric/esophageal varices
- Mallory-Weiss tear
- Malignancy
- Aortoenteric fisulta
- Boerhaave
- Dieulafoy's lesion
- Angiodysplasia
- Hemobilia
- Hemorrhagic gastritis, EtOH
- Celiac disease
- Dengue
- Other intrabdominal bleeds
- Lower GI bleeding
- Hemorrhagic pancreatitis
- Splenic rupture
- Subcapsular cavernous hemangiomas
- Peliosis hepatis
Mimics of GI Bleeding
- Hemoptysis
- Vaginal/Urethra bleeding
- ENT bleeding
- Dietary (Iron, bismuth, beets)
- Swallowed maternal blood (in neonate)
Evaluation
Work-Up
- CBC (rule out anemia)
- LFTs
- Lipase
- Consider acute abdominal series if concern for perforation (>50 years old; concerning abdominal exam)
- Consider RUQ US
- Consider ECG
- Consider troponin
Evaluation
- Diagnosis not typically definitively made in ED (requires endoscopy or H. pylori test)
- Depending on clinical certainty can consider initial empiric treatment
Management
Perforated
Surgical emergency
- Consult surgery
- Antibiotics to cover abdominal flora
- IVF
Non-Perforated
- Stop NSAIDs and ETOH
- PPI
- Generally heal ulcers faster than H2 blockers
- Omeprazole 20-40mg QD
- H2 blocker
- Famotidine 20-40mg QD
- Ranitidine 75-150mg BID
- Eradicate H. pylori if identified in symptomatic patient
- Triple Therapy: PPI + clarithromycin 500mg BID + (amoxicillin 1g or metronidazole 500mg) BID x 10-14d
- Quadruple Therapy: PPI + bismuth subsalicylate 524mg QID + metronidazole 250mg QID and tetracycline 500mg QID x 10-14d
Disposition
- Normally outpatient management, unless complication (see below)
Red Flags
Any of the following suggest need for endoscopy referral:
- Age >55yr
- Unexplained weight loss
- Early satiety
- Persistent vomiting
- Dysphagia
- Anemia or GI bleeding
- Abdominal mass
- Persistent anorexia
- Jaundice
Complications
- Hemorrhage
- Perforation (see above)
- Obstruction
- Occurs due to:
- Scarring of gastric outlet
- Edema due to active ulcer
See Also
References
- ↑ Vakil N. Peptic ulcer disease: Management. UpToDate. https://www.uptodate.com/contents/peptic-ulcer-disease-management?search=ulcer treatment&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H1. Published September 16, 2019. Accessed November 5, 2019.