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. Most commonly occurs in anterior wall of duodenum.
   2. Abrupt onset of severe epigastric pain
   3. Pts may not have history of ulcer-like sx
   4. 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