Peptic Ulcer Disease
Kinsley Ojukwu
Background
- Peptic ulcer disease (PUD) occurs when there is a break (ulceration) in the lining of the stomach or duodenum.
- Ulcer is >5mm break in the mucosa, with extension through muscularis mucosa or deeper layers. Erosion is <5mm.
Etiology
- H-Pylori infection > NSAID use >>> ZES associated gastrinoma
- Other associated factors: smoking, EtOH, acute stress, malignancy, and glucocorticoids in combination with NSAIDs
Presentation
- Episodic aching, gnawing, or burning epigastric pain; N/V, heartburn alleviated by antiacids.
- Gastric ulcers (pain worse w/eating, weight loss); duodenal ulcers (pain better w/eating, worse on empty stomach, worse at night)
- May be asymptomatic until complications such as hemorrhage or perforation
- Alarm features: unintentional weight loss, persistent vomiting, melena, unexplained iron deficiency anemia, progressive dysphagia, early satiety, palpable abdominal mass, left supraclavicular lymphadenopathy (Virchow node)
Evaluation
- EGD for complicated PUD, patients with alarm sx, or dyspepsia w/ age >60
- CBC, H Pylori testing if no strong NSAID use
- H. Pylori endoscopic tests (biopsy urease, histology, culture)
- H. Pylori non-endoscopic tests (Serology – IgG, Urea Breath test, stool antigen
- Most H. Pylori tests affected by PPI and/or antibiotic use; stop PPI 1-2 weeks prior to testing; serology testing is not useful post treatment.
Management
- General: treat underlying cause, encourage smoking cessation, limit ETOH, stop NSAIDs
- Uncomplicated peptic ulcer (non H. pylori)
- Oral PPI (e.g., omeprazole 20 to 40 mg daily) x 4 weeks (duodenal ulcers) or 8 weeks (gastric ulcers)
- Uncomplicated peptic ulcer and + H. Pylori
- Oral PPI BID x14 days with combination antibiotic regimen
- Macrolide exposure/resistance: Bismuth Quadruple Therapy
- No Macrolide exposure/resistance: Clarithromycin Triple Therapy (Amoxicillin)
- FYI: There is an order set for H pylori regimen in EPIC at VUMC
- Confirm H. pylori eradication (via stool antigen test, urease breath test, or EGD >4 weeks after completion of therapy. If not eradicated, re-treat:
- Clarithromycin Triple Therapy -> Bismuth Quadruple Therapy
- Bismuth Quadruple Therapy -> Levofloxacin Triple Therapy
- Complicated peptic ulcer (bleeding, perforation, gastric outlet obstruction)
- Gastric or duodenal ulcer perforation is a surgical emergency; will clinically present as peritonitis, but may be subtle in older/immunocompromised pts
- Fluid resuscitation, NG decompression, acid suppression, empiric antibiotic therapy, EGS consult
- EGD is indicated to determine etiology and for possible treatment, however surgery is often indicated.
- IV PPI (if bleeding: IV PPI for 72 hrs after endoscopic treatment, then oral PPI)
Additional Information
- Continue maintenance PPI therapy (omeprazole 20 mg daily) for the following:
- Peptic ulcer >2 cm and age >50 or multiple co-morbidities
- Frequently recurrent peptic ulcers (>2 in one year)
- H. pylori-negative, NSAID-negative ulcer disease
- Failure to eradicate H. pylori (including salvage therapy)
- Condition requiring long term aspirin/NSAID use
- Persistent ulcer on repeat EGD (if performed)
- Indications for repeat EGD (8-12 weeks):
- Persistent/recurrent symptoms despite medical therapy
- Complicated ulcer (bleeding), with evidence of ongoing bleeding
- Giant gastric ulcer (>2 cm) or features of malignancy at initial endoscopy
- Gastric ulcer that was not biopsied or inadequately sampled on initial EGD
- Gastric ulcer in pt w/risk factors for gastric cancer (>50 yo, H. pylori, immigrant from high prevalence area [Japan, Korea, Taiwan, Costa Rica], FHx, presence of gastric atrophy, adenoma, dysplasia, intestinal metaplasia)
- In refractory dyspepsia, consider alternative etiologies: malignancy, infection (CMV), Crohn’s, eosinophilic gastroenteritis – all can mimic PUD and present as ulcers in the stomach and duodenum
