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==
==Clinical Features==
*Burning epigastric pain
===Non-Perforated===
*Burning [[epigastric pain]]
**May awaken patient at night (gastric contents empty)
**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 with PUD:
*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==
==Differential Diagnosis==
{{Template:Abdominal Pain DDX Epigastric}}
{{Abdominal Pain DDX Epigastric}}
{{UGIB DDX}}


==Evaluation==
==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===
===Work-Up===
*CBC (r/o anemia)
*CBC (rule out anemia)
*LFTs
*[[LFTs]]
*Lipase
*Lipase
*Consider [[acute abdominal series]] if concern for perforation (>50 years old; concerning abdominal exam)
*Consider [[acute abdominal series]] if concern for perforation (>50 years old; concerning abdominal exam)
*Conside [[RUQ US]]
*Consider [[RUQ US]]
*Consider [[ECG]]
*Consider [[ECG]]
*Consider troponin
*Consider troponin


===Evaluation===
===Evaluation===
*Diagnosis not typically definitively made in ED (requires endoscopy or H pilori test)
[[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
*Depending on clinical certainty can consider initial empiric treatment


==Management==
==Management==
===Perforated===
''Surgical emergency''
*Consult surgery
*[[Antibiotics]] to cover abdominal flora
*[[IVF]]
===Non-Perforated===
*Stop [[NSAIDs]] and [[ETOH]]
*Stop [[NSAIDs]] and [[ETOH]]
*[[PPI]]
*[[PPI]]
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*Eradicate [[H. pylori]] if identified in symptomatic patient
*Eradicate [[H. pylori]] if identified in symptomatic patient
**Triple Therapy: PPI + [[clarithromycin]] 500mg BID + ([[amoxicillin]] 1g or [[metronidazole]] 500mg) BID x 10-14d
**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
**Quadruple Therapy: [[PPI]] + [[bismuth subsalicylate]] 524mg QID + [[metronidazole]] 250mg QID and [[tetracycline]] 500mg QID x 10-14d


==Disposition==
==Disposition==
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*Unexplained weight loss
*Unexplained weight loss
*Early satiety
*Early satiety
*Persistent vomiting
*Persistent [[vomiting]]
*Dysphagia
*[[Dysphagia]]
*Anemia or GI bleeding
*[[Anemia]] or [[GI bleeding]]
*Abdominal mass
*Abdominal mass
*Persistent anorexia
*Persistent anorexia
*Jaundice
*[[Jaundice]]


==Complications==
==Complications==
*Perforation (see above)
*Hemorrhage
*Hemorrhage
**[[Upper GI Bleeding]]
**[[Upper GI Bleeding]]
*Perforation
*[[SBO|Obstruction]], due to:
**Most commonly occurs in anterior wall of duodenum. 
**Scarring of gastric outlet
**Abrupt onset of severe epigastric pain
**Edema due to active ulcer
**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


==See Also==
==See Also==
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==References==
==References==
 
<references/>
[[Category:GI]]
[[Category:GI]]

Revision as of 13:21, 2 May 2020

Background

Stomach anatomy
Stomach wall anatomy
Duodenum with major anatomical landmarks.
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[1]
  • 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)
  • 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

Upper gastrointestinal bleeding

Mimics of GI Bleeding

Evaluation

Free intra-abdominal air below the diaphragm (a complication of perforated ulcer).
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

Perforated

Surgical emergency

Non-Perforated

Disposition

  • Normally outpatient management, unless complication (see below)

Red Flags

Any of the following suggest need for endoscopy referral:

Complications

See Also

References

  1. ↑ 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.
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