Peptic Ulcer Disease

A peptic ulcer is a defect in the gastric or duodenal mucosa that extends through the muscularis mucosa into the deeper layers of the wall.

Causes: H.pylori infection, NSAIDS, aspirin, Zollinger-Ellison syndrome, Hyperparathyroidism, Crohn disease, burns, head injury, organ failure

Symptoms and Signs: 70 percent of peptic ulcers are asymptomatic; Symptoms include epigastric pain, early satiety, nausea

Gastric Ulcer (GU): Occur later in life, 55-70 years; Eating exacerbates pain; Nausea and weight loss occur more commonly in GU patients than DU patients. Should be biopsied because 5% of gastric ulcers are malignant.

Duodenal Ulcer (DU): Younger age of onset, 30-55 years; Eating relieves pain; The typical pain pattern in DU occurs 90 min to 3 h after a meal and is frequently relieved by antacids or food. Awakens the patient at night. Do not require biopsy because DUs are virtually never malignant and do not require biopsy.

Q: What is the most discriminating symptom in DU? it awakes the patient from sleep (between midnight and 3 A.M)

Ulcer complications: Bleeding, gastric outlet obstruction, fistulization, perforation

Diagnosis: Upper endoscopy or radiologic studies, Testing for Helicobacter pylori: Urea breath test, stool antigen test, serologic testing

Treatment:

Removal of offending factors.

Antacids: rarely used by physicians. Most often used by patients. Aluminum hydroxide can produce constipation and phosphate depletion; magnesium hydroxide may cause loose stools.

H₂ receptor antagonists: cimetidine, ranitidine, famotidine, nizatidine. Cimetidine can cause reversible gynecomastia and impotence.

Proton Pump Inhibitors: Omeprazole, Esomeprazole, Lansoprazole, Rabeprazole, Pantoprazole etc

Cytoprotective agents: Sucralfate

Bismuth-Containing Preparations: Bismuth subsalicylate

Prostaglandin analogues: Misoprostol (contraindicated in women who may be pregnant)

Surgery: Vagotomy and drainage

H.pylori treatment:

Clarithromycin Triple: PPI + Clarithromycin + Amoxicillin for 14 days, Approved by FDA.

Bismuth Quadruple: PPI + Bismuth subsalicylate + Tetracycline + Metronidazole for 10-14 days, not approved by FDA

Levofloxacin Triple: PPI + Levofloxacin + Amoxicillin for 5-7 days, not approved by FDA.

-In patients treated for H. pylori, eradication of infection should be confirmed four or more weeks after the completion of therapy. Tests to confirm eradication: urea breath test, fecal antigen test, or upper endoscopy

-Approximately 60 percent of peptic ulcers heal spontaneously but with eradication of H. pylori infection, ulcer healing rates are >90 percent.

Potential Adverse effects of Proton Pump Inhibitor Drugs:

-Chronic kidney disease, acute kidney disease, acute interstitial nephritis, hypomagnesemia, Clostridium difficile, Community-acquired pneumonia, bone fracture

-Long-term acid suppression, especially with PPIs, has been associated with a higher incidence of community-acquired pneumonia as well as community and hospital acquired Clostridium difficile–associated disease.

– long-term use of PPIs was associated with the development of hip fractures in older women.

Q: What is the most commonly identified risk factor for peptic ulcer bleeding? NSAIDS use

Q: What is the most frequent finding on physical examination in patients with GU or DU? Epigastric tenderness.

Q: What is the procedure of choice for the diagnosis of duodenal and gastric ulcers? Upper Endoscopy  

Q: What are the antisecretory drugs of choice for treating NSAID-related ulcers? PPIs

Q: What is the most common complication associated with peptic ulcers? GI bleeding

T or F?The majority of patients with peptic ulcers may be asymptomatic.True

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