Peptic Ulcer Disease
Kimberly Schuster
Background
- PUD is a mucosal defect >5mm in the stomach or duodenum. Most commonly caused by H. Pylori or NSAID use; together they increase bleeding risk >6-fold.
- Complications: bleeding (73%), perforation (9%), gastric outlet obstruction (3%).
Presentation
- Uncomplicated PUD: epigastric burning or gnawing pain; may be worse with meals (gastric) or improve with meals and recurs at night (duodenal). Many patients are asymptomatic.
- Complicated PUD: hematemesis/melena (bleeding), acute abdomen/peritonitis (perforation), recurrent vomiting (gastric outlet obstruction), or refractory/multiple ulcers + diarrhea (ZES).
- Alarm features: weight loss, persistent vomiting, anemia, dysphagia, early satiety, GI bleeding, abdominal mass, Virchow node.
Evaluation
- EGD indicated for: age ≥ 60 with dyspepsia, any age with alarm features, suspected complications, persistent symptoms after test-and-treat.
- Test-and-treat strategy (age <60, no alarms): urea breath test or stool antigen preferred; hold PPI 1-2 weeks before testing; avoid serology for test of cure (can’t distinguish active from past infection).
Management
- General: smoking cessation, limit alcohol, stop NSAIDs if possible.
- Acid Suppression:
- PPIs first-line: duodenal ulcer (4 weeks) or gastric ulcer (4-8 weeks; 8 weeks if >2cm).
- Vonoprazan (PCAB): more potent acid suppression, superior for H.pylori eradication and NSAID ulcer prevention.
- H2 blockers only if PPI intolerance.
- NSAID-Induced Ulcers:
- Discontinue NSAID is possible.
- If NSAID required: treat with PPI.
- Eradicate H.pylori if present.
- FYI: there’s an order set for H.pylori regimen in EPIC at VUMC.
| Setting | Regimen | Notes |
|---|
| Treatment-naïve (preferred) | Bismuth quadruple (BQT): PPI + bismuth + tetracycline + metronidazole | First-line when susceptibility unknown. Eradication rate 75–90%. |
| Alternative first-line (no PCN allergy) | Rifabutin triple: PPI + rifabutin + amoxicillin — OR — Vonoprazan dual (Voquezna Dual Pak) | Available as co-packaged Dual or Triple Pak. |
| Salvage | 1st: BQT (if not yet tried) → 2nd: Rifabutin triple → 3rd: Levofloxacin triple or concomitant (susceptibility confirmed) → 4th: High-dose dual therapy | Clarithromycin/levofloxacin only if susceptibility confirmed (US resistance 32%/38%). Rifabutin resistance: 0%. |
- Confirm eradication in all patients: urea breath test or stool antigen ≥ 4 weeks after treatment and ≥2 weeks off PPI. If not eradicated, switch drug class
Complications
- Perforation: surgical emergency (resuscitation, IV PPI, BSA, surgical consult, lactate, CBC).
- Bleeding Ulcer: CBC, endoscopic therapy, IV PPI BID for 72 hours-->high-dose PPI for 8 weeks (can decrease dose after 4 weeks).
Follow-Up
- Maintenance PPI indicated for: recurrent ulcers, large (>2cm) gatric ulcers, ongoing NSAID/Aspirin use, persistent H. pylori-negative ulcers.
- Repeat EGD (8-12 weeks): large gastric ulcers, persistent symptoms, inadequate biopsy, concern for malignancy.
- If refractory: consider malignancy, CMV, Crohn disease, eosinophilic gastroenteritis, ZES, ongoing NSAID use, or persistent H.pylori.
