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Peptic Ulcer Disease

Michelle Izmaylov

Background

  • Ulceration in the GI tract wall extending through the muscularis mucosa into deeper layers
  • Most common in the stomach and proximal duodenum
  • Less common in the lower esophagus, the distal duodenum, or the jejunum
    • ↑ suspicion for unopposed hypersecretory states, like Zollinger-Ellison syndrome
  • Causes: NSAID use and Helicobacter pylori >> steroids, malignancy, and acute stress

Presentation

  • Episodic gnawing or burning epigastric pain, 2 - 5 hr after meals, nausea, vomiting, heartburn, bloating, postprandial belching, and loss of appetite
  • Nocturnal pain: acid is secreted in absence of a food buffer
  • Classic teaching for ulcers: Gastric (pain worse w/eating); Duodenal (pain better w/eating)
  • May be asymptomatic until complications such as hemorrhage or perforation
  • Alarm features: unintentional weight loss, persistent vomiting, melena, progressive dysphagia, early satiety, recurrent vomiting, palpable abdominal mass, lymphadenopathy, family history of upper gastrointestinal cancer, and iron deficiency anemia

Evaluation

  • CBC and H Pylori testing if no strong NSAID use history
  • Urea breath or stool antigen (pt needs to stop PPI for 1-2 weeks, to avoid false - for both)
  • EGD: if alarm features or patient is older than 55

Management

  • General: treat underlying cause (i.e. H. pylori, stop NSAIDs, etc), encourage smoking cessation, and limit alcohol intake to 1 drink/day.
  • If complicated peptic ulcer (i.e. bleeding, perforation, or gastric outlet obstruction):
    • EGD to determine etiology and for possible treatment
    • IV PPI (if bleeding IV PPI for 72 hrs after endoscopic treatment oral PPI)
  • If uncomplicated peptic ulcer (not caused by H. pylori):
    • Antisecretory therapy with oral PPI (i.e. omeprazole 20 to 40 mg daily):
      • If caused by NSAIDs: Duration: \<1 cm ulcer 4-6 wks; ≥1 cm ulcer 6-8 wks
    • If not caused by NSAIDs, Duration:
      • Duodenal ulcer: 4 weeks
      • Gastric ulcer: 8 weeks
  • If ulcer caused by H. pylori:
    • Treat with PPI BID for 14 days with an appropriate combination antibiotic regimen.
    • Confirm H. pylori eradication (via stool antigen test, urease breath test, or EGD >4 weeks after completion of therapy). If not eradicated, retreat

Additional Information

  • Continue maintenance PPI therapy (omeprazole 20 mg daily) for the following:
    • Peptic ulcer >2 cm and age >50 or multiple co-morbidities
    • Frequently recurrent peptic ulcers (>2 in one year)
    • H. pylori-negative, NSAID-negative ulcer disease
    • Failure to eradicate H. pylori (including salvage therapy)
    • Condition requiring long term aspirin/NSAID use
    • Persistent ulcer on repeat EGD (if performed)
  • Indications for repeat EGD (8-12 weeks):
    • Persistent/recurrent symptoms despite medical therapy
    • Complicated ulcer (bleeding), with evidence of ongoing bleeding
    • Giant gastric ulcer (>2 cm) or features of malignancy at index endoscopy
    • Gastric ulcer that was not biopsied or inadequately sampled on initial EGD
    • Gastric ulcer in pt w/risk factors for gastric cancer (>50 yo, H. pylori, immigrant from high prevalence area [Japan, Korea, Taiwan, Costa Rica], FHx, presence of gastric atrophy, adenoma, dysplasia, intestinal metaplasia)