Peptic ulcer disease

Background

• Recurrent ulcerations in the stomach and proximal duodenum
• Majority of cases related to H. pylori or NSAID use
  • H. pylori found in 30-40% of U.S. population
  • NSAIDs inhibit prostaglandin synthesis (decreases mucus and bicarb production)

Diagnosis

• Burning epigastric pain
  • May awaken pt 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 w/ PUD:
  • Postprandial pain, food intolerance, nausea, retrosternal pain, belching

Work-Up

1. CBC (r/o anemia)
2. LFTs
3. Lipase
4. ?Acute abd series
5. ?RUQ US
6. ?ECG
7. ?Troponin

Differential Diagnosis

Epigastric Pain

• Gastroesophageal reflux disease (GERD)
• Peptic ulcer disease with or without perforation
  • Zollinger-Ellison syndrome
• Gastritis
• Pancreatitis
• Gallbladder disease
  • Acute cholecystitis
  • Cholangitis
  • Symptomatic cholelithiasis
  • Acalculous cholecystitis
• 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

Treatment

1. Eradicate H. pylori if identified in symptomatic pt
   1. PPI + clarithromycin + (amoxicillin or metronidazole) x14d
2. Stop NSAIDs
3. PPI
   1. Generally heal ulcers faster than H2 blockers
   2. Omeprazole 20-40mg QD
4. H2 Blockers
   1. Famotidine 20-40mg QD
   2. Ranitidine 75-150mg BID

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

1. Hemorrhage
   1. Upper GI Bleeding
2. Perforation
   1. Abrupt onset of severe epigastric pain
   2. Pts may not have history of ulcer-like sx
   3. Consult surgery
3. Obstruction
   1. Occurs due to:
      1. Scarring of gastric outlet
      2. Edema due to active ulcer

See Also

• Abdominal Pain

Source

Tintinalli