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
Lifestyle changes you need to make in PUD?
- Discontinue NSAIDs and use Acetaminophen for pain control if possible.
- Acid suppression–Antacids
- Smoking cessation
- No dietary restrictions unless certain foods are associated with problems.
- Alcohol in moderation
- Men under 65: 2 drinks/day
- Men over 65 and all women: 1 drink/day - Stress reduction
Who should receive Prophylactic Prevention treatment in PUD?
- Pts with NSAID-induced ulcers who require daily NSAID therapy
- Pts older than 60 years
- Pts with a history of PUD or a complication such as GI bleeding
- Pts taking steroids or anticoagulants or patients with significant comorbid medical illnesses
Prophylactic regimens?
use of a prostaglandin analogue or a proton pump inhibitor
1. Misoprostol (Cytotec) 100-200 mcg PO 4 times per day
2. Omeprazole (Prilosec) 20-40 mg PO every day
3. Lansoprazole (Prevacid) 15-30 mg PO every day
Complications of PUD?
- Perforation & Penetration—into pancreas, liver and retroperitoneal space
- Peritonitis
- Bowel obstruction, Gastric outflow obstruction, & Pyloric stenosis
- Bleeding–occurs in 25% to 33% of cases and accounts for 25% of ulcer deaths.
- Gastric CA
Who gets surgery for PUD?
People who do not respond to medication, or who develop complications
Surgery for PUD?
- Vagotomy - cutting the vagus nerve to interrupt messages sent from the brain to the stomach to reducing acid secretion.
- Antrectomy - remove the lower part of the stomach (antrum), which produces a hormone that stimulates the stomach to secrete digestive juices. A vagotomy is usually done in conjunction with an antrectomy.
- Pyloroplasty - the opening into the duodenum and small intestine (pylorus) are enlarged, enabling contents to pass more freely from the stomach. May be performed along with a vagotomy.
Evaluation and follow up if H. Pylori positive?
- H. Pylori Positive: retesting for tx efficacy
i. Urea breath test—no sooner than 4 weeks after therapy to avoid false negative results
ii. Stool antigen test—an 8 week interval must be allowed after therapy.
Evaluation and follow up if H. pylori is negative?
H. Pylori Negative: evaluate symptoms after one month. Patients who are controlled should cont. 2-4 more weeks.
When do you refer a patient?
If symptoms persist then refer to specialist for additional diagnostic testing.
