Peptic Ulcer Disease

Question 1

PUD

Answer 1

Break in mucosa and submucosa lining; defined as ulcerations or erosion in the stomach and duodenum due to the corrosive action of gastric fluid

HCl and pepsin in acidic solution plays a role in mucosal breaks regardless of the provoking cause (H. pylori, aspirin, or NSAIDs)

Major (chronic) forms:
1. DUODENAL (80%) – exacerbations occur, necessitating surgery in 5-10% cases

2. GASTRIC (20%) – less curvature of the stomach, near the pylorus

Question 2

Protective vs. hostile factors

Answer 2

PROTECTIVE FACTORS:

1. Prostaglandins
2. Bicarb
3. Blood flow
4. Mucous production

HOSTILE FACTORS:

1. H. pylori and smoking (most common)
2. Gastric acid
3. NSAIDs

Question 3

Risk factors

Answer 3

PUD risk factors:
1. H. pylori (toxin released by this bacteria promotes inflammation and ulceration) – pt is predisposed to gastric CA; Transmission: Fecal or water-to-oral (inversely proportional to socioeconomic status)

2. NSAIDs (H. pylori is present in 22-63% of pts taking NSAIDs) – Inhibits prostaglandin = Increased gastric acid and pepsin and decreased bicarb. and mucous production
3. Excessive smoking – inhibits prostaglandin, bicarb., blood flow, and gastric emptying
4. Acid hypersecretion syndrome (Zollinger Ellison syndrome)
5. Genetic (20-50%)

Question 4

Clinical manifestations

Answer 4

Duodenal ulcer:

1. Pain improved with food or antacids
2. Burning epigastric pain
3. Pain aggravated by fasting

Gastric ulcer:

1. Pain triggered or worsened by eating (shortly after meals)
2. Not relieved by antacids

**Acute pain may be a sign of a complication (perforation) or it may be another disease entity (pancreatitis, GB disease, CAD)

Question 5

Diagnosis

Answer 5

R/o other priority issues (EKG, LFTs, amylase, abdominal ultrasound; gallstones, CPK)

XRAY – r/o free air (perforation)

Upper endoscopy – biopsy (CA, cytology, H. pylori)

Labs – CBC, FOBT

Urease breath test – presence of H. pylori

Fasting serum gastrin – r/o Zollinger’s

Question 6

Medical management

Answer 6

Goals:

1. Pain relief
2. Ulcer healing
3. Prevention of ulcer recurrence
4. Reduction of complication

Medications:

1. H2 receptor antagonist (Ranitidine)
2. PPI (Omeprazole)
3. Sucralfate – binds to ulcer tissue; acts as a barrier

Diet:

1. Avoid dietary irritants (caffeine, ETOH, spices)
2. Small meals (~6)
3. Avoid smoking

Surgery – only performed for non-healing or bleeding ulcers

Monitor for complications:

1. GI hemorrhage – abdominal pain, changes in VS, decreased H&H, hematemesis, blood in stool
2. Intestinal infarction or perforation – abdominal pain, changes in VS, increased WBC
3. Rule out other issues – i.e. CV (EKG)

Additional: Abdominal assessment, VS, monitor gastric pH, pain, labs (electrolytes, BUN, CBC), weight, and collaboration (dietary, pharmacy, pt resources)

Question 7

Pt education

Answer 7

Teaching:
1. Avoid eating 2 hrs. before bedtime – eating increases gastric secretion

2. Diet (small meals) – avoid NSAIDs, spicy foods, ETOH, smoking
3. Know when to contact PCP – hematemesis, unusual abdominal pain, blood in stool
4. Meds.