Peptic Ulcer Disease Flashcards
What is peptic ulcer disease?
A circumscribed ulceration of the gastrointestinal mucosa occurring in areas exposed to acid and pepsin and most often caused by Helicobacter pylori infection.
PUD demographics?
Higher prevalence in developing countries
- H. Pylori is sometimes associated with socioeconomic status and poor hygiene
Describe duodenal ulcers?
duodenal sites are 4x as common as gastric sites
Epidemiology of duodenal ulcers?
- most common in middle age
- peak 30-50 years
- Male to female ratio—4:1
- Genetic link: 3x more common in 1st degree relatives
- more common in patients with blood group O
Risk factors for developing duodenal ulcers?
- associated with increased serum pepsinogen
- H. pylori infection common
up to 95% - smoking is twice as common
Epidemiology of gastric ulcers?
- common in late middle age
- incidence increases with age
- Male to female ratio—2:1
- More common in patients with blood group A
Risk factors for developing gastric ulcers?
- Use of NSAIDs - associated with a three- to four-fold increase in risk of gastric ulcer
- Less related to H. pylori than duodenal ulcers – about 80%
- 10 - 20% of patients with a gastric ulcer have a concomitant duodenal ulcer
What is a peptic ulcer?
A peptic ulcer is a mucosal break, 3 mm or greater, that can involve the stomach or duodenum
Contributing factors to PUD?
- H pylori
- NSAIDs
- acid
- pepsin
Aggressive factors in PUD?
- smoking
- ethanol
- bile acids
- aspirin
- steroids
- stress
Protective factors in PUD?
- mucus
- bicarbonate
- mucosal blood flow
- prostaglandins
- hydrophobic layer
- epithelial renewal
- Increased risk when older than 50 d/t decrease protection
Etiology of peptic ulceration?
In both types of peptic ulceration,
gastric and duodenal, there is an imbalance between secretion and neutralization of secreted acid.
1. In duodenal ulcers there is an oversecretion of acid
2. in gastric ulcers there is an impairment of mucosal protection
- When an imbalance occurs, PUD might develop
Pain of ulceration feels like?
”gnawing”, “aching”, or “burning”
Pain in duodenal vs gastric ulcers?
- Duodenal ulcers: occurs 1-3 hours after a meal and may awaken patient from sleep. Pain is relieved by food, antacids, or vomiting.
- Gastric ulcers: food may exacerbate the pain while vomiting relieves it
Subjective clinical features of PUD?
- Nausea
- vomiting
- belching
- dyspepsia
- bloating
- chest discomfort
- anorexia
- hematemesis &/or melena may also occur.
Note: nausea, vomiting, & weight loss more common with Gastric ulcers
Objective findings in PUD?
- Epigastric tenderness
- Guaiac (occult blood test)positive stool resulting from occult blood loss
- Succussion splash resulting from scaring or edema due to partial or complete gastric outlet obstruction
What is a succussion splash?
describes the sound obtained by shaking an individual who has free fluid and air or gas in a hollow organ or body cavity
- Usually elicited to confirm intestinal or pyloric obstruction
How to perform a succussion splash?
Done by gently shaking the abdomen by holding either side of the pelvis
- A positive test occurs when a splashing noise is heard, either with or without a stethoscope
- It is not valid if the pt has eaten or drunk fluid within the last three hours.
Ddx for PUD?
Neoplasm of the stomach
Pancreatitis
Pancreatic cancer
Diverticulitis
Nonulcer dyspepsia (also called functional dyspepsia)
Cholecystitis
Gastritis
GERD
MI—not to be missed if having chest pain
Diagnostic plan for PUD?
- Stool for fecal occult blood
- Labs: CBC (R/O bleeding), liver function test, amylase, and lipase.
- H. Pylori can be diagnosed by urea breath test, blood test, stool antigen assays, & rapid urease test on a biopsy sample.
- Upper GI Endoscopy
Gold standard for diagnosis of PUD?
upper GI endoscopy
- Preferred diagnostic test because its highly sensitive for dx of ulcers and allows for biopsy to rule out malignancy and rapid urease tests for testing for H. Pylori
Upper GI endoscopy is especially necessary for?
Any pt >50 yo with new onset of symptoms or those with alarm markings including anemia, weight loss, or GI bleeding
Treatment plan for H. pylori?
Medications: Triple therapy for 14 days is considered the treatment of choice.
- In the setting of an active ulcer, continue qd proton pump inhibitor therapy for additional 2 weeks.
Goal: complete elimination of H. Pylori. Once achieved reinfection rates are low. Compliance!
Medical management of H. pylori?
Proton Pump Inhibitor + clarithromycin and amoxicillin
1. Omeprazole (LOSEC): 20 mg PO bid for 14 d or
2. Lansoprazole (Prevacid): 30 mg PO bid for 14 d or
3. Rabeprazole (Aciphex): 20 mg PO bid for 14 d or
4. Esomeprazole (Nexium): 40 mg PO qd for 14 d plus Clarithromycin (Biaxin): 500 mg PO bid for 14 and
5. Amoxicillin (Amoxil): 1 g PO bid for 14 d
6. Can substitute Flagyl 400 mg PO bid for 14 d if allergic to Clarithromycin
