Peptic Ulcer

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Contents 1 More Specific Terms 2 Etiology 3 Pathology 4 Clinical-manifestations 5 Laboratory 6 Diagnostic-procedures 7 Radiology 8 Complications 9 Differential-diagnosis 10 Management 11 More General Terms 12 Additional Terms 13 References

More Specific Terms

• gastroduodenitis
• NSAID gastropathy

Etiology

• Helicobacter pylori infection [6]

• associated with 90-95% of duodenal ulcers
• associated with 70-90% of gastric ulcers
• major cause of chronic active gastritis

• non-steroidal anti-inflammatory drugs ( NSAIDs) [6]

• may cause gastric (antral) or duodenal ulcers
• addition of steroids potentiates risk of PUD
• accounts for majority of PUD not associated with H pylori
• presence of Helicobacter pylori does not confer additional risk [4]

• ethacrynic acid
• severe physiologic stress

• burns
• CNS trauma
• surgery
• severe medical illness

• hypersecretory states

• gastrinoma ( Zollinger-Ellison syndrome)
• multiple endocrine neoplasia ( MEN)-1
• antral G cell hyperplasia
• systemic mastocytosis
• basophilic leukemia

• viral infection

• Herpes
• Cytomegalovirus

• radiation
• chemotherapy
• vascular insufficiency: crack cocaine
• duodenal obstruction
• diseases associated with peptic ulcer disease (PUD)

• cirrhosis of the liver
• chronic obstructive pulmonary disease
• renal failure
• renal transplantation

Pathology

• imbalance between protective & injurious factors

• protective factors: mucous, bicarbonate ( alkaline tide), mucosal blood flow, prostaglandins, hydrophobic mucosal layer, restitution, epithelial renewal
• injurious factors: H. pylori, acid, pepsin, bile acids, smoking, ethanol, NSAIDs, steroids, stress

• risk factor: smoking
• genetic

• familial tendency
• increased frequency in persons with blood group O

Clinical-manifestations

• patients commonly asymptomatic at diagnosis

• peptic ulcer often detected during evaluation for positive fecal occult blood
• elderly patients are more likely to be asymptomatic & have an increased risk of GI bleeding, especially if taking NSAIDs

• epigastric pain & tenderness

• gnawing or burning pain
• onset of pain 1-3 hours after meals
• pain relieved by antacids
• pain may occur at night
• pain may radiate to back
• pain is generally intermittent
• duodenal ulcer more likely than gastric ulcer to cause pain that awakens patient at night

• nausea/vomiting:

• vomiting may be related to gastric outlet obstruction

• dyspepsia: belching, bloating, distention, fatty food intolerance
• heartburn
• anorexia/ weight loss
• hematemesis
• melena

Laboratory

• fecal occult blood:

• guaiac-positive stool may initiate diagnostic workup

• complete blood count ( CBC)
• serum chemistries

• serum creatinine
• serum calcium, serum albumin
• serum gastrin in recurrent, refractory PUD or in patients with a family history of Zollinger-Ellison (ZE) syndrome

• diagnostic tests for Helicobacter pylori

• serology for H pylori
• urease breath test
• predictive value of H pylori testing without EGD is low [2]

• secretin-stimulation test

• used in conjunction with serum gastrin
• distinguish ZE from other hypergastrinemic states

• achlorhydria
• pharmacologic agents

• proton-pump inhibitors
• H2 receptor antagonists

• measurement of acid secretion

• used in conjunction with serum gastrin & secretin-stimulation test
• distinguish ZE from other hypergastrinemic states
• not useful by itself in evaluation of PUD

Diagnostic-procedures

• esophagogastroduodenoscopy ( EGD) [2]

• identifies gastric ulcers, duodenal ulcers
• biopsy all gastric ulcers to rule out malignancy
• test for Helicobacter pylori
• patients < 55 years of age with dyspepsia may be treated empirically for without EGD [2]

Radiology

• upper GI series

Complications

• gastrointestinal bleeding (15%)

Differential-diagnosis

• gastroesophageal reflux disease ( GERD)
• dyspepsia without ulcer ( gastroduodenitis)

• pharmacologic agents
• theophylline
• digitalis
• caffeine

• biliary tract disease
• pancreatitis
• musculoskeletal
• carcinoma

• gastric
• duodenal (rare)
• pancreatic

• Crohn's disease
• infectious agents

• giardiasis
• tuberculosis
• Mycobacterium avium-intracellulare

• sarcoidosis
• Menetrier's disease
• lymphoma

Management

• test for & treat Helicobacter pylori if positive; then, empiric treatment with proton pump inhibitor for patients < 55 years & no alarm features of dyspepsia
• endoscopy is indicated for:

• patients > 55 years, or
• other alarm features of dyspepsia [2]

• proton pump inhibitors

• duration of therapy 4-8 weeks [2]
• 80-100% healing of ulcer after completion of therapy
• omeprazole ( Prilosec) 20-40 mg QD
• lansoprazole ( Prevacid) 15-30 mg QD
• addition of H2-receptor antagonist may be synergistic (see proton pump inhibitor)

• H2-receptor antagonist [2]

• duration of therapy 6-8 weeks
• 90-95% healing of ulcer after completion of therapy
• cimetidine ( Tagamet) 400 mg BID or 800 mg QHS
• famotidine ( Pepcid) 20 mg BID or 40 mg QHS
• nizatidine ( Axid) 150 mg BID or 300 mg QHS
• ranitidine ( Zantac) 150 mg BID or 300 mg QHS

• prostaglandins

• inhibit acid secretion by inhibiting activation of adenylate cyclase in gastric parietal cells by histamines
• used primarily as prophylactic agents, not recommended for routine treatment of PUD
• Misoprostol ( Cytotec) 200 ug QID

• antimuscarinic agents:

• pirenzipine
• telenzipine
• not approved for used in the US

• antacids
• cytoprotective agents

• sucralfate ( Carafate) 1 g QID or 2 g BID for 6-8 weeks
• bismuth subsalicylate

• nitrates ( Isordil, nitroglycerin) may protect against bleeding ulcers [3]
• smoking cessation
• stop & avoid NSAIDs
• avoid excess alcohol
• stress-reduction
• surgery for peptic ulcer complications
• follow-up:

• endoscopy to document healing of gastric ulcer & to gastric cancer
• repeat endoscopy &/or H pylori testing not needed in the absence of complications [2]
• 1 year recurrence rate < 10% if Helicobacter pylori is eradicated
• follow-up H pylori testing (proof of eradication)

• urease breath test [2]
• H pylori serology maintains elevated titers > 1 year after successful eradication

• antiplatelet therapy

• combination aspirin 80 mg + proton pump inhibitor in patients with healed peptic ulcers is safer than clopidogrel ( Plavix) [5]
• aspirin-related ulcers will heal with proton pump inhibitor regardless of whether aspirin is continued or switched to clopidogrel [7]

More General Terms

• upper gastrointestinal hemorrhage
• ulcer
• gastrointestinal ulcer
• chronic gastrointestinal disease

Additional Terms

• antiulcer agent
• dyspepsia (indigestion)
• Helicobacter pylori

References

1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 319-21
2. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 15 American College of Physicians, Philadelphia 1998, 2006, 2009
3. Journal Watch 20(20):161, 2000 Lanas A, Bajador E, Serrano P, Fuentes J, Carreno S, Guardia J, Sanz M, Montoro M, Sainz R. Nitrovasodilators, low-dose aspirin, other nonsteroidal antiinflammatory drugs, and the risk of upper gastrointestinal bleeding. N Engl J Med. 2000 Sep 21;343(12):834-9. PMID: [1]
4. Lowe A, UCLA Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 25-28, 2002
5. Journal Watch 25(4):29, 2005 Chan FK, Ching JY, Hung LC, Wong VW, Leung VK, Kung NN, Hui AJ, Wu JC, Leung WK, Lee VW, Lee KK, Lee YT, Lau JY, To KF, Chan HL, Chung SC, Sung JJ. Clopidogrel versus aspirin and esomeprazole to prevent recurrent ulcer bleeding. N Engl J Med. 2005 Jan 20;352(3):238-44. PMID: [2] Cryer B. Reducing the risks of gastrointestinal bleeding with antiplatelet therapies. N Engl J Med. 2005 Jan 20;352(3):287-9. No abstract available. PMID: [3]
6. Ramsoekh D, van Leerdam ME, Rauws EA, Tytgat GN. Outcome of peptic ulcer bleeding, nonsteroidal anti- inflammatory drug use, and Helicobacter pylori infection. Clin Gastroenterol Hepatol. 2005 Sep;3(9):859-64. PMID: [4]
7. Luo J-C et al. Randomised clinical trial: Rabeprazole plus aspirin is not inferior to rabeprazole plus clopidogrel for the healing of aspirin-related peptic ulcer. Aliment Pharmacol Ther 2011 Sep; 34:519 PMID: [5]
8. Peptic Ulcer: NIH Institute and Center Resources [6]
9. University of Michigan Health System (UMHS) [7]
10. National Guideline Clearinghouse Peptic ulcer disease. (University of Michigan Health System) ngc-guideline: [8]

peptic ulcer disease (PUD)