Peptic Ulcer Disease

Question 1

What are symptoms of PUD?

Answer 1

Asymptomatic or sx that wax and wane
vague, dull abdominal pain
early satiety

Question 2

Primary ulcers

Answer 2

duodenal with no underlying cause. They are chronic and tend to recur.

Question 3

Secondary ulcers

Answer 3

Most often gastric, more acute and associated with known ulcerogenic events.

Question 4

Causes of secondary ulcers

Answer 4

NSAIDS, ASA, corticosteroids
Head trauma
Alcohol
Stress

Question 5

What is the gold standard diagnostic test for PUD?

Answer 5

Endoscopy with mucosal biopsy.

Validates H. pylori

Question 6

Alarm symptoms for PUD

Answer 6

Unintentional weight loss
Early satiety
Dysphagia or odynophagia
GI bleed
Iron deficiency anemia
Persistent vomiting
Palpable abdominal mass
Adenopathy
Consider EGD also patients >50 or FH upper GI malignancy
2st degree relative w/ malignancy

Question 7

When do you do an endoscopy for PUD?

Answer 7

With any alarm symptom

Question 8

Diagnostic tests for H. pylori

Answer 8

Histology and culture biopsies from endoscopy are gold standard.
C-urea breath test - do not use if on acid suppressors
ELISA Serum IgG titer - remains elevated years after tx.

Question 9

H. pylori transmission route

Answer 9

oral-fecal bacterial infection

Question 10

H. pylori treatment

Answer 10

1st line: H2RA (pepcid/zantac) or PPI (prevacid/prilosec)
Triple therapy or can add doxy for quadruple therapy
PPI x 8 weeks

Question 11

When do you do test of cure after H. pylori treatment?

Answer 11

4 weeks after treatment

Question 12

Alternatives to oral ibuprophen

Answer 12

topical patches

Question 13

A patient has persistent epigastric pain occurring 2 to 3 hours after a meal. Which test is definitive for diagnosis peptic ulcer in this patient?

a. Barium swallow with radiography
b. Breath test or stool antigen testing for H. pylori
c. Endoscopy with biopsy of gastric mucosa
d. Physical exam with percussion of the upper abdomen

Answer 13

ANS: C
Endoscopy provides the most accurate diagnosis of PUD and allows biopsy of multiple areas to exclude malignancy. Barium swallow may still be performed in patients unwilling to undergo endoscopy. Breath tests and stool antigen testing for H. pylori can confirm a bacterial cause. Physical exam generally yields negative findings.

Question 14

What is the best treatment for H. pylori-related peptic ulcer disease?

a. H2RA and clarithromycin for 14 days
b. H2RA, bismuth, metronidazole, and tetracycline for 10 to 14 days
c. PPI and clarithromycin for 14 days
d. PPI, amoxicillin, and clarithromycin for 10 days

Answer 14

ANS: C
A PPI and clarithromycin for 14 days has documented improved effectiveness over other regimens. Use of an H2RA is cheaper.

Question 15

A patient who has been taking an NSAID for osteoarthritis pain has peptic ulcer disease. What is the initial step in treating this patient?

a. Discontinue the NSAID
b. Order prostaglandin therapy
c. Prescribe a proton pump inhibitor
d. Recommend an H2 receptor antagonist

Answer 15

ANS: A
The first step in treating medication-induced peptic ulcer is to discontinue the medication. H2 receptor antagonists are the first anti-secretory medications prescribed. Proton pump inhibitors are more expensive and are used as second-line treatment. Prostaglandin therapy helps protect the gastric and duodenal mucosa and is used if NSAIDS cannot be discontinued.