PEPTIC ULCER DISEASE

Question 1

DDx

Answer 1

Pancreatitis
Peptic Ulcer Disease
Gastritis
Acute Cholecystitis

*Mesenteric Ischemia
*Perforated Viscus
*SBO

*Thoracic Aortic Dissection

*Acute Coronary Syndrome

*AAA

Question 2

Etiology: Most common

Answer 2

H. Pylori (80% DU, 60% GU)
ASA / NSAIDs

Other:
Smoking
EtOH (increases risk of bleeding PUD)
Stress

Question 3

Clinical Features

Answer 3

Epigastric abdominal pain: aggravated by food (GU), relieved with food (DU)

Dyspepsia

Nausea / Vomiting

Question 4

Red Flags

Answer 4

Peritonitis
Vomiting
Hematemesis / BRBPR / Melena
Weight loss
Early satiety / anorexia
Dysphagia

Question 5

Complications

Answer 5

Perforation
UGIB
Gastric Outlet Obstruction

Question 6

Investigations

Answer 6

CBC

Coags

LFTs

Lipase

Lactate

+/-CT Tomogram r/o perforation

CT abdo / pelvis with IV contrast: r/o GI bleed

H. Pylori Stool antigen - Hold abx, bismuth for 1 month, ppi for 2 weeks, H2 blocker for 24 hrs

Urea Breath Test - Hold abx, bismuth for 1 month, ppi for 2 weeks, H2 blocker for 24 hrs

EGD with biopsy - gold standard

Question 7

Initial Management: Non-Perforated

Answer 7

Stop NSAIDs, EtOH

Panoloc 40 mg PO daily

Famotidine: 40 mg PO daily

H.Pylori:
14 days
PPI: Esomeprazole 40 mg orally every 24 hours OR Omeprazole 20 mg orally every 12 hours
PLUS
Bismuth Subsalicylate 524 mg PO qid
PLUS
Metronidazole 500 mg po qid
PLUS
Tetracycline 500 mg PO qid

Question 8

Initial Management: Perforated

Answer 8

Piperacillin/tazobactam 4.5 g intravenous piggyback every 6 hours

OR

ESBL Risk:
Meropenem 1 g intravenous piggyback every 8 hours

Pantoprazole 80 mg intravenous bolus over 30 minutes followed by a continuous intravenous infusion of 8 mg per hour

On DOAC:
administer 50 international units (IU) (max dose 2,000 IU) of 4-factor prothrombin complex concentrate.

Consult Surgery Early