Peptic ulcer disease

Background

A benign gastric ulcer (from the antrum of a gastrectomy specimen).

• Recurrent ulcerations in the stomach and proximal duodenum
  • Defect in the gastric or duodenal wall that extends through the muscularis mucosa into the deeper layers of the wall
• Majority of cases related to H. pylori or NSAID use
  • H. pylori found in 30-40% of U.S. population
  • NSAIDs inhibit prostaglandin synthesis (decreases mucus and bicarb production)

Clinical Features

• Burning epigastric pain
  • May awaken patient at night (gastric contents empty)
• Abrupt onset of severe pain may indicate perforation
• Abrupt onset of back pain may indicate penetration into the pancreas
• The following symptoms are NOT associated with PUD:
  • Postprandial pain, food intolerance, nausea, retrosternal pain, belching

Complications

• Hemorrhage
  • Upper GI Bleeding
• Perforation
  • Most commonly occurs in anterior wall of duodenum.
  • Abrupt onset of severe epigastric pain
  • Patients may not have history of ulcer-like symptoms
  • Upright or left lateral decub XR for intraabdominal air
  • Consult surgery
• Obstruction
  • Occurs due to:
    • Scarring of gastric outlet
    • Edema due to active ulcer

Differential Diagnosis

Epigastric Pain

• Gastroesophageal reflux disease (GERD)
• Peptic ulcer disease with or without perforation
  • Zollinger-Ellison syndrome
• Gastritis
• Pancreatitis
• Gallbladder disease
  • Acute cholecystitis
  • Cholangitis
  • Symptomatic cholelithiasis
  • Acalculous cholecystitis
• Myocardial Ischemia
• Splenic Infarctionenlargement/rupture/aneurysm
• Pericarditis/Myocarditis
• Aortic dissection
• Hepatitis
• Pyelonephritis
• Pneumonia
• Pyogenic liver abscess
• Fitz-Hugh-Curtis Syndrome
• Hepatomegaly due to CHF
• Bowel obstruction
• SMA syndrome
• Pulmonary embolism
• Bezoar
• Ingested foreign body

Upper gastrointestinal bleeding

• Peptic ulcer disease (most common cause)
  • Zollinger-Ellison syndrome
• Gastritis/esophagitis
• Gastric/esophageal varices
• Mallory-Weiss tear
• Malignancy
• Aortoenteric fisulta
• Boerhaave
• Dieulafoy's lesion
• Angiodysplasia
• Hemobilia
• Hemorrhagic gastritis, EtOH
• Celiac disease
• Dengue
• Other intrabdominal bleeds
  • Lower GI bleeding
  • Hemorrhagic pancreatitis
  • Splenic rupture
  • Subcapsular cavernous hemangiomas
  • Peliosis hepatis

Mimics of GI Bleeding

• Hemoptysis
• Vaginal/Urethra bleeding
• ENT bleeding
• Dietary (Iron, bismuth, beets)
• Swallowed maternal blood (in neonate)

Evaluation

Perforated duodenal ulcer presenting with a subphrenic abscess: (A) air-fluid collection (asterisk) with stranding (arrow). (B) air-fluid collection (asterisk) extends to the perihepatic space with extraluminal air bubbles (arrow).

Work-Up

• CBC (rule out anemia)
• LFTs
• Lipase
• Consider acute abdominal series if concern for perforation (>50 years old; concerning abdominal exam)
• Consider RUQ US
• Consider ECG
• Consider troponin

Evaluation

Acute duodenal acute duodenal mucosal ulcer on endoscopy

• Diagnosis not typically definitively made in ED (requires endoscopy or H. pylori test)
• Depending on clinical certainty can consider initial empiric treatment

Management

• Stop NSAIDs and ETOH
• PPI
  • Generally heal ulcers faster than H2 blockers
  • Omeprazole 20-40mg QD
• H2 blocker
  • Famotidine 20-40mg QD
  • Ranitidine 75-150mg BID
• Eradicate H. pylori if identified in symptomatic patient
  • Triple Therapy: PPI + clarithromycin 500mg BID + (amoxicillin 1g or metronidazole 500mg) BID x 10-14d
  • Quadruple Therapy: PPI + bismuth subsalicylate 524mg QID + metronidazole 250mg QID and tetracycline 500mg QID x 10-14d

Disposition

• Normally outpatient management, unless complication (see below)

Red Flags

Any of the following suggest need for endoscopy referral:

• Age >55yr
• Unexplained weight loss
• Early satiety
• Persistent vomiting
• Dysphagia
• Anemia or GI bleeding
• Abdominal mass
• Persistent anorexia
• Jaundice

See Also

• Epigastric abdominal pain