Peptic Ulcer Disease

Peptic ulcer disease is characterized by ulcers in the stomach and/or duodenum that penetrate the mucosa to reach the deeper layers of the GI tract. Gastritis is a pre-cursor of peptic ulcer disease. We typically define peptic ulcers as gastric or duodenal; be aware that patients can have both. Infection by H. pylori and use of NSAIDs are top causes of gastritis and peptic ulcer disease. Cigarette smoking is an important risk factor. Other Causes: Drug-induced PUD from bisphosphonates, clopidogrel, anticoagulants, potassium supplements, corticosteroids, chemotherapeutic drugs, cocaine. Hormonal, such as gastrinomas Postsurgical, radiation therapy Mechanical obstruction Infiltrating diseases such as Crohn disease. Thanks to improvements in sanitation, peptic ulcers caused by H. pylori are on the decline; however, cases due to NSAID use are increasing (possibly due to an aging population relying on NSAIDs for age-related pain relief). Contrary to popular belief, psychological stress and spicy foods do not cause peptic ulcers. Signs and symptoms of peptic ulcer disease include epigastric pain, GI bleeding, and nausea or vomiting; however, be aware that many patients are asymptomatic, especially in the early phases. Recurrent epigastric pain that is relieved by food or antacids. If pain returns shortly after a meal, gastric ulcer is likely; if pain returns 2-4 hours after meal, duodenal ulcer is more likely. Peptic ulcers are the most common cause of upper GI bleeding (though most ulcers do not bleed); patient has black/tarry stools with blood. Concern if patient has early satiety, anorexia, bleeding, recurrent vomiting, and weight loss; see complications below. Diagnosis relies on upper endoscopy to visualize potential lesions and biopsies to look for signs of inflammation and damage, infection by H. pylori, and malignancy. For patients who are younger than 60 years-old without alarming symptoms: weight loss, anemia, bloody stools, or dysphagia (trouble with swallowing), the focus should be on diagnosis of active H. pylori infection with non-invasive testing and response to a proton pump inhibitor (PPI, (eg, omeprazole)). The urea breath test or stool antigen test are non-invasive tests for H. pylori. Note that H. pylori antibody serologies do not distinguish between active and inactive disease. For patients who are older than 60 years-old or with any alarming symptoms**: weight loss, anemia, bloody stools, or dysphagia (trouble with swallowing), upper endoscopy should be performed. Treatment of peptic ulcer disease involves proton pump inhibitors, H2RAs, NSAID discontinuation, and, when present, H. pylori eradication with antibiotics. H. Pylori antibiotics 14 days:

• Triple therapy: clarithromycin + amoxicillin or metronidazole; PPI
• Quadruple therapy: Bismuth subsalicylate, metronidazole, tetracycline; PPI

Stop use of NSAIDs, smoking, and alcohol. In the case of H. pylori infection, we need to perform follow-up tests to confirm eradication and avoid relapse. Gastric ulcers are typically the result of reduced mucosal protection against gastric acids. H. pylori infection*is present in approximately 70% of cases. Early detection and treatment of gastric ulcers is crucial because of their higher risk of malignancy rate (5-10%). Be aware that Zollinger-Ellison syndrome is a rare cause of gastric ulcers. Duodenal ulcers are typically caused by increased acid production, with possible reduced mucosal protection. H. pylori is present in approximately 90% of cases. Duodenal ulcers are typically benign. Gastric ulcer pain increases upon eating, leading patients to avoid food and lose weight, whereas duodenal ulcer pain relieves pain and may therefore be associated with weight gain. However, be aware that these patterns are not always consistent. Hemorrhage is the most common complication; it can be treated with endoscopic hemostasis therapies and proton pump inhibitors. Perforation occurs when an ulcer creates a hole in the GI tract; this is an emergency, and can cause peritonitis.

• Perforation has a high mortality rate (up to 30%).

• Patients tend to present with sudden abdominal pain, tachycardia, and abdominal rigidity.

• With imaging we'll see free abdominal air under the diaphragm; this is called pneumoperitoneum.

• Be aware that "penetration" occurs when a peptic ulcer erodes into another organ instead of opening into the peritoneum.

Gastric outlet obstruction is mechanical blockage.

• In acute cases, obstruction is due to inflammation and edema in acute cases; in chronic cases, obstruction is due to fibrosis and scarring.

• Patients experience early satiety with nausea, vomiting, bloating, and pain.

• Imaging will show gastric distention, and endoscopy can reveal the cause.

• Try treatment of the peptic ulcer disease before attempting surgical solutions.