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.


==Diagnosis==
==Clinical Features==
*Burning epigastric pain
===Non-Perforated===
**May awaken pt at night (gastric contents empty)
*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 w/ 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


==Work-Up==
===Perforated===
#CBC (r/o anemia)
*Abrupt onset of severe epigastric pain
#LFTs
*Patients may not have history of ulcer-like symptoms
#Lipase
#?Acute abd series
#?RUQ US
#?ECG
#?Troponin


==Differential Diagnosis==
==Differential Diagnosis==
{{Template:Abdominal Pain DDX Epigastric}}
{{Abdominal Pain DDX Epigastric}}
{{UGIB DDX}}


==Treatment==
==Evaluation==
*Eradicate H. pylori if identified in symptomatic pt
[[File:Free air under diaphram.png|thumb|Free intra-abdominal air below the diaphragm (a complication of perforated ulcer).]]
**PPI + [[clarithromycin]] + ([[amoxicillin]] or [[metronidazole]]) x14d
[[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).]]
*Stop NSAIDs
===Work-Up===
*PPI
*CBC (rule out anemia)
**Generally heal ulcers faster than H2 blockers
*[[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<ref>Walan A, Bader JP, Classen M, Lamers CB, Piper DW, Rutgersson K, Eriksson S. Effect of omeprazole and ranitidine on ulcer healing and relapse rates in patients with benign gastric ulcer. N Engl J Med. 1989 Jan 12;320(2):69-75. doi: 10.1056/NEJM198901123200201. PMID: 2643037.</ref>
**[[Omeprazole]] 20-40mg QD
**[[Omeprazole]] 20-40mg QD
*H2 Blockers
*[[H2 blocker]]
**[[Famotidine]] 20-40mg QD
**[[Famotidine]] 20-40mg QD
**[[Ranitidine]] 75-150mg BID
**[[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==
==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==
#Hemorrhage
*Perforation (see above)
##[[Upper GI Bleeding]]
*Hemorrhage
#Perforation
**[[Upper GI Bleeding]]
##Most commonly occurs in anterior wall of duodenum. 
*[[SBO|Obstruction]], due to:
##Abrupt onset of severe epigastric pain
**Scarring of gastric outlet
##Pts may not have history of ulcer-like sx
**Edema due to active ulcer
##Consult surgery
#Obstruction
##Occurs due to:
###Scarring of gastric outlet
###Edema due to active ulcer


==See Also==
==See Also==
*[[Abdominal Pain]]
*[[Epigastric abdominal pain]]
 
==Source==
Tintinalli


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

Revision as of 00:05, 18 March 2021

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.
  2. Walan A, Bader JP, Classen M, Lamers CB, Piper DW, Rutgersson K, Eriksson S. Effect of omeprazole and ranitidine on ulcer healing and relapse rates in patients with benign gastric ulcer. N Engl J Med. 1989 Jan 12;320(2):69-75. doi: 10.1056/NEJM198901123200201. PMID: 2643037.