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Peptic Ulcer Disease

Dr Waseem ChistiFellow Emergency Medicine

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Definition

A circumscribed ulceration of the gastrointestinal mucosaoccurring in areas exposed toacid and pepsin and most oftencaused by Helicobacter pyloriinfection.

(Uphold & Graham, 2003)

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PUD DemographicsHigher prevalence in developing countries

H. Pylori is sometimes associated withsocioeconomic status and poor hygiene

In the US :Lifetime prevalence is ~10%.PUD affects ~4.5 million annually.Hospitalization rate is ~30 pts per 100,000 cases.Mortality rate has decreased dramatically in thepast 20 years

approximately 1 death per 100,000 cases

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C omparing Duodenal

and Gastric Ulcers

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Duodenal Ulcers

duodenal sites are 4x as common as gastric sitesmost common in middle age

peak 30-50 years

Male to female ratio4:1Genetic link: 3x more common in 1 st degreerelativesmore common in patients with blood group O

associated with increased serum pepsinogenH. pylori infection common

up to 95%

smoking is twice as common

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Gastric Ulcers

common in late middle ageincidence increases with age

Male to female ratio2:1More common in patients with blood group A Use of NS A IDs - associated with a three- to four-foldincrease in risk of gastric ulcer Less related to H. pylori than duodenal ulcers

about 80%10 - 20% of patients with a gastric ulcer have aconcomitant duodenal ulcer

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E tiologyA peptic ulcer is a mucosal break, 3 mm or greater,that can involve the stomach or duodenum.The most important contributing factors are H pylori,

NS A IDs, acid, and pepsin.A dditional aggressive factors include smoking,ethanol, bile acids, aspirin, steroids, and stress.Important protective factors are mucus, bicarbonate,

mucosal blood flow, prostaglandins, hydrophobiclayer, and epithelial renewal.Increased risk when older than 50 d/t decrease protection

When an imbalance occurs, PUD might develop.

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O bjective Data

Epigastric tendernessGuaic-positive stool resulting from occult blood lossSuccussion splash resulting from scaring or edemadue to partial or complete gastric outlet obstruction

A succussion splash describes the sound obtained byshaking an individual who has free fluid and air or gas in ahollow organ or body cavity.Usually elicited to confirm intestinal or pyloric obstruction.Done by gently shaking the abdomen by holding either sideof the pelvis. A positive test occurs when a splashing noiseis heard, either with or without a stethoscope. It is not validif the pt has eaten or drunk fluid within the last three hours.

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Differential Diagnosis

Neoplasm of the stomachPancreatitisPancreatic cancer DiverticulitisNonulcer dyspepsia (also called functionaldyspepsia)CholecystitisGastritisGERDMInot to be missed if having chest pain

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Diagnostic Plan

Stool for fecal occult bloodLabs: CBC (R/O bleeding), liver function test,amylase, and lipase.H. Pylori can be diagnosed by urea breath test, bloodtest, stool antigen assays, & rapid urease test on abiopsy sample.Upper GI Endoscopy: A ny pt >50 yo with new onset of symptoms or those with alarm markings includinganemia, weight loss, or GI bleeding.

Preferred diagnostic test b/c its highly sensitive for dx of ulcers and allows for biopsy to rule out malignancy and rapidurease tests for testing for H. Pylori.

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T reatment Plan: H. Pylori

Medications: Triple therapy for 14 days is considered thetreatment of choice.

Proton Pump Inhibitor + clarithromycin and amoxicillin

Omeprazole (Prilosec): 20 mg PO bid for 14 d or Lansoprazole (Prevacid): 30 mg PO bid for 14 d or Rabeprazole ( A ciphex): 20 mg PO bid for 14 d or Esomeprazole (Nexium): 40 mg PO qd for 14 dplus

Clarithromycin (Biaxin): 500 mg PO bid for 14 andA moxicillin ( A moxil): 1 g PO bid for 14 dCan substitute Flagyl 500 mg PO bid for 14 d if allergic to PCN

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contd.

In the setting of an active ulcer, continueqd proton pump inhibitor therapy for additional 2 weeks.Goal: complete elimination of H. Pylori.

Once achieved reinfection rates are low.Compliance!

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T reatment Plan: Not H. Pylori

Medicationstreat with Proton PumpInhibitors or H2 receptor antagonists to assist

ulcer healingH2: Tagament, Pepcid, A xid, or Zantac for up to 8weeksPPI: Prilosec, Prevacid, Nexium, Protonix, or

A ciphex for 4-8 weeks.

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L ifestyle C hanges

Discontinue NS A IDs and use A cetaminophen for pain control if possible.A cid suppression-- A ntacids

Smoking cessationNo dietary restrictions unless certain foods areassociated with problems.A lcohol in moderation

Men under 65: 2 drinks/dayMen over 65 and all women: 1 drink/day

Stress reduction

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PreventionConsider prophylactic therapy for the following patients:

Pts with NS A ID-induced ulcers who require daily NS A IDtherapyPts older than 60 yearsPts with a history of PUD or a complication such as GIbleedingPts taking steroids or anticoagulants or patients withsignificant comorbid medical illnesses

Prophylactic regimens that have been shown to dramaticallyreduce the risk of NS A ID-induced gastric and duodenal ulcersinclude the use of a prostaglandin analogue or a proton pumpinhibitor.

Misoprostol (Cytotec) 100-200 mcg PO 4 times per dayOmeprazole (Prilosec) 20-40 mg PO every day

Lansoprazole (Prevacid) 15-30 mg PO every day

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C omplications

Perforation & Penetrationinto pancreas,liver and retroperitoneal space

PeritonitisBowel obstruction, Gastric outflowobstruction, & Pyloric stenosisBleeding--occurs in 25% to 33% of cases andaccounts for 25% of ulcer deaths.Gastric C A

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S urgery

People who do not respond to medication, or whodevelop complications:

Vagotomy - cutting the vagus nerve to interrupt messages

sent from the brain to the stomach to reducing acidsecretion.A ntrectomy - remove the lower part of the stomach(antrum), which produces a hormone that stimulates thestomach to secrete digestive juices. A vagotomy is usuallydone in conjunction with an antrectomy.Pyloroplasty - the opening into the duodenum and smallintestine (pylorus) are enlarged, enabling contents to passmore freely from the stomach. May be performed alongwith a vagotomy.

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E valuation/Follow-up/Referrals

H. Pylori Positive: retesting for tx efficacyUrea breath testno sooner than 4 weeks after therapy to avoid false negative results

Stool antigen testan 8 week interval must beallowed after therapy.

H. Pylori Negative: evaluate symptoms after one month. Patients who are controlled

should cont. 2-4 more weeks.If symptoms persist then refer to specialist for additional diagnostic testing.

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T hank you.