Module 6.0 - Peptic Ulcer Disease Flashcards
What is peptic ulcer disease?
- A defect in the gastric or duodenal wall that extends through the muscularis mucosa into the deeper layers of the wall.
- Approximately 500,000 new cases each year
What are the 2 most common types of peptic ulcer disease?
1. Gastric ulcers - form on the stomach lining; most commonly noted in the lesser curvature of the stomach near the incisura angularis; are 3-4 x more prevalent than duodenal ulcers in NSAID users; peak age of incidence is 55-70 years of age
2. Duodenal ulcers - form on the lining of the upper part of the small intestine (duodenum); are 4x more common than gastric ulcers; peak age of incidence is 30-55 years of age
What causes peptic ulcer disease?
#1, Helicobacter pylori is present 30% - 60% of gastric ulcers (where NSAIDs cannot be implicated) and in > 85% of duodenal ulcers
- Increase in amount of hydrochloric acid (produced by the gastric parietal cells) and pepsin leading to a breakdown of the protective mucosal layers
- Inflammation of GI lining
#2. NSAIDs - cause changes in protective mucous layer, leading to ulcers in some people; dependent on multiple factors, such as NSAID type, dose and duration of use
What are some risk factors for peptic ulcer disease development?
- Genetics
- History of smoking
- Drugs (NSAIDs)
- Crohn’s disease
- Lymphoma
- Acid hyper-secretory states, such as Zollinger-Ellison syndrome (disease caused by non-insulin secreting tumors of the pancreas, which secrete excessive amounts of gastrin)
- Cytomegalovirus
What symptoms are associated with peptic ulcer disease?
- Upper abdominal pain or discomfort (burning or hunger like feeling)
- Stomach pain, belching, bloated feeling after eating
- Heartburn or acid reflux
- Nausea
- Vomiting – may be associated with hematemesis
- Blood in stools – hematochezia or melena
What are some physical exam findings associated with duodenal ulcers?
- Epigastric pain usually 1-3 hours after eating
- Usually relieved by antacid or food ingestion
- Nocturnal pain that awakens from sleep
- Heartburn –suggests reflux disease
- Epigastric tenderness- midline or right of midline
What are some physical exam findings associated with gastric ulcers?
- Epigastric pain
- Pain not usually relieved by food ingestion
- Food may precipitate symptoms
- Nausea and anorexia
- Epigastric pain located 1 inch or farther to right of midline
What labs are drawn to diagnose peptic ulcer disease?
- Labs are usually normal in uncomplicated disease.
- CBC – may indicate anemia from chronic or acute blood loss
- Leukocytosis – indicates perforation
- Elevated serum amylase – when associated with epigastric pain can suggest ulcer penetration into the pancreas
- Fasting serum gastrin levels- to rule out Zollinger-Elison syndrome
What diagnostic tests are used to diagnose peptic ulcer disease?
- Upper GI series (barium swallow) – used infrequently when upper endoscopy cannot be performed due to other conditions; barium allows digestive tract to be visualized on x-rays
- Upper endoscopy - gold standard for diagnosis; identifies superficial ulcers also, biopsy can be performed, electrocautery of any bleeding ulcers at same time, obtain gastric pH measurements, H.pylori can be detected; high cost.
What 4 tests are used to detect an H. Pylori infection?
- Histopathology- endoscopic biopsy- gold standard for diagnosis
- Urea breath test: Positive test implies active infection; expensive; Proton pump inhibitors (PPIs) can cause false-negatives- discontinue for 7-14 days prior
- Serum H.pylori antibody testing: positive test may be indicative of previous infection BUT NOT active infection; lower sensitivity and specificity than other tests
- Fecal antigen for H.pylori: detects active infection ; good test post treatment to see if infection has cleared; PPIs can again cause false-negative and need to be held 7-14 days prior
What are the clinical signs of peptic ulcer bleeding?
Mostly affect older people; occurs approx. 20% of cases.
- Hematemesis
- Melena
- Hematochezia
- ‘Coffee ground’ emesis
What are the physical exam signs of peptic ulcer bleeding?
- Pallor
- Tachycardia
- Hypotension
- Diaphoresis
What are the lab findings associated with bleeding peptic ulcers?
- Decreased hematocrit secondary to bleeding (consider hemo-dilution from IV fluids also)
- Blood urea nitrogen (BUN) may be elevated secondary to absorption of nitrogen from small intestine and/or due to pre-renal azotemia.
How can bleeding ulcers be diagnosed?
- Upper endoscopy after the patient has stabilized.
- If actively bleeding, upper endoscopy performed with cauterization, clipping of responsible blood vessels and injection with epinephrine to stop bleeding. If unsuccessful, then surgery or angiographic embolization performed.
What are the clinical symptoms associated with a peptic ulcer perforation?
- Severe abdominal pain
- Tachycardia
- Referred pain to shoulders, back or right upper quadrant
What is the medical therapy for H. Pylori Infection?
- The initial antibiotic regimen should be guided by the presence of risk factors for macrolide resistance (avoid clarithromycin-based therapy) and presence of penicillin allergy.
-
Risk factors for macrolide resistance:
- Prior exposure to macrolide therapy FOR ANY REASON
- High local clarithromycin resistance rates > 15% or eradication rates with clarithromycin triple therapy < 85%
- In the U.S given the limited information on antimicrobial resistance rates, it is generally assumed clarithromycin resistance rates are > 15% unless local data indicates otherwise.
- In patients with risk factors for macrolide resistance- use bismuth quadruple therapy.
- In patients without risk factors for macrolide resistance- use clarithromycin-based triple therapy.
- Duration of all therapies- 14 days
