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

Red Flags

Any of the following suggest endoscopy referral

1. Age >55yr
2. Unexplained weight loss
3. Early satiety
4. Persistent vomiting
5. Dysphagia
6. Anemia or GI bleeding
7. Abdominal mass
8. Persistent anorexia
9. Jaundice

DDx

Abdominal Pain#Epigastric

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

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

Source

Tintinalli