Peptic ulcer disease: Difference between revisions
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==Background== | ==Background== | ||
[[File:Gray1046.png|thumb|Stomach anatomy]] | |||
[[File:Illu stomach2.jpg|thumb|Stomach wall anatomy]] | |||
[[File:Duodenumanatomy.jpg|thumb|Duodenum with major anatomical landmarks.]] | |||
[[File:Benign gastric ulcer 1.jpg|thumb|A benign gastric ulcer (from the antrum of a gastrectomy specimen).]] | |||
*Recurrent ulcerations in the stomach and proximal duodenum | *Recurrent ulcerations in the stomach and proximal duodenum | ||
*Majority of cases related to H. pylori or NSAID use | **Defect in the gastric or duodenal wall that extends through the muscularis mucosa into the deeper layers of the wall<ref>Vakil N. Peptic ulcer disease: Management. UpToDate. https://www.uptodate.com/contents/peptic-ulcer-disease-management?search=ulcer treatment&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H1. Published September 16, 2019. Accessed November 5, 2019.</ref> | ||
**H. pylori found in 30-40% of U.S. population | *Majority of cases related to [[H. pylori]] or [[NSAID]] use | ||
**NSAIDs inhibit prostaglandin synthesis (decreases mucus and bicarb production) | **[[H. pylori]] found in 30-40% of U.S. population | ||
**[[NSAIDs]] inhibit prostaglandin synthesis (decreases mucus and bicarb production) | |||
*Perforation most commonly occurs in anterior wall of duodenum. | |||
== | ==Clinical Features== | ||
*Burning epigastric pain | ===Non-Perforated=== | ||
**May awaken | *Burning [[epigastric pain]] | ||
**May awaken patient at night (gastric contents empty) | |||
*Abrupt onset of severe pain may indicate perforation | *Abrupt onset of severe pain may indicate perforation | ||
*Abrupt onset of back pain may indicate penetration into the pancreas | *Abrupt onset of [[back pain]] may indicate penetration into the pancreas | ||
*The following symptoms are NOT associated | *The following symptoms are NOT associated with PUD: | ||
**Postprandial pain, food intolerance, nausea, retrosternal pain, belching | **Postprandial pain, food intolerance, nausea, retrosternal pain, belching | ||
== | ===Perforated=== | ||
*Abrupt onset of severe epigastric pain | |||
*Patients may not have history of ulcer-like symptoms | |||
== | ==Differential Diagnosis== | ||
{{Abdominal Pain DDX Epigastric}} | |||
{{UGIB DDX}} | |||
== | ==Evaluation== | ||
[[ | [[File:Free air under diaphram.png|thumb|Free intra-abdominal air below the diaphragm (a complication of perforated ulcer).]] | ||
[[File:PMC3835032 1752-1947-7-257-2.png|thumb|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=== | ||
[[File:Duodenal ulcer01.jpg|thumb|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== | |||
===Perforated=== | |||
''Surgical emergency'' | |||
*Consult surgery | |||
*[[Antibiotics]] to cover abdominal flora | |||
*[[IVF]] | |||
===Non-Perforated=== | |||
*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]] | |||
==Complications== | ==Complications== | ||
*Perforation (see above) | |||
*Hemorrhage | |||
**[[Upper GI Bleeding]] | |||
*[[SBO|Obstruction]], due to: | |||
**Scarring of gastric outlet | |||
**Edema due to active ulcer | |||
==See Also== | ==See Also== | ||
*[[Epigastric abdominal pain]] | |||
== | ==References== | ||
<references/> | |||
[[Category:GI]] | [[Category:GI]] |
Revision as of 13:21, 2 May 2020
Background
- 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[1]
- Majority of cases related to H. pylori or NSAID use
- Perforation most commonly occurs in anterior wall of duodenum.
Clinical Features
Non-Perforated
- 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
Perforated
- Abrupt onset of severe epigastric pain
- Patients may not have history of ulcer-like symptoms
Differential Diagnosis
Epigastric Pain
- Gastroesophageal reflux disease (GERD)
- Peptic ulcer disease with or without perforation
- Gastritis
- Pancreatitis
- Gallbladder disease
- 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)
- 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
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
- Diagnosis not typically definitively made in ED (requires endoscopy or H. pylori test)
- Depending on clinical certainty can consider initial empiric treatment
Management
Perforated
Surgical emergency
- Consult surgery
- Antibiotics to cover abdominal flora
- IVF
Non-Perforated
- 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
Complications
- Perforation (see above)
- Hemorrhage
- Obstruction, due to:
- Scarring of gastric outlet
- Edema due to active ulcer
See Also
References
- ↑ Vakil N. Peptic ulcer disease: Management. UpToDate. https://www.uptodate.com/contents/peptic-ulcer-disease-management?search=ulcer treatment&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H1. Published September 16, 2019. Accessed November 5, 2019.