#35 – Peptic Ulcer Disease



***LISTEN TO THE PODCAST HERE***



Definitions

  • Dyspepsia
    • Upper abdominal pain or discomfort
  • Gastritis
    • Epithelial or endothelial damage with histologic evidence of inflammation
  • 2 types
    • Gastric
    • Duodenal

Epidemiology

  • Annual incidence in developed countries 0.1-0.19%, or 0.7 cases per 1000 person-years
  • Lifetime prevalence of PUD in 10-20% in pylori (+) patients vs 5-10% in H.pylori (-) patients
  • Increases with age
    • 13x higher risk of bleeding in patients > 70yo
  • More common in males
  • Differences between Gastric and Duodenal Ulcers
    • DU occur up to 20 years before GU
    • DU 5x more common than GU

Etiologies

There are numerous causes of PUD and include infections, stress, medications, alcohol, cirrhosis, neoplasms, etc.  The two main causes in developed countries are:

  • Helicobacter pylori
    • Spiral gram negative rod
    • Decreasing incidence due to better hygiene, OTC medications, and antibiotic use
  • Non-Steroidal Antiflammatory Drugs (NSAIDs)
    • 1-4% per year risk of PUD
    • Risk factors
      • Prior history of PUD or pylori infection
      • Dose
      • Duration
      • Age > 75 years
      • Co-therapy
        • Corticosteroids, anticoagulants, SSRI, bisphosphonates, antiplatelets


Clinical Manifestations

  • Up to 70% of peptic ulcers are asymptomatic
    • Present later with complications
    • Up to 80% present with bleeding without preceding symptoms
  • Dyspepsia is the most common symptoms
    • May also have radiation to the back
  • Relation to food intake
    • GU – Worse
    • DU – Better
  • Night symptoms
    • GU – 1/3 of patients
    • DU – 2/3 of patients
  • Nausea, vomiting, anorexia, early satiety, epigastric fullness


Complications

  • Bleeding
  • Gastric Outlet Obstruction
  • Penetration
    • Change in typical symptoms
  • Perforation
    • 2-10% perforation rate
      • Duodenal – 60%
      • Antrum – 20%
      • Gastric Body – 20%

Red Flags


Work-up

  • Endoscopy
    • Up to 90% sensitivity in identifying ulcer
    • Next step if any red flags
    • Malignant features requiring biopsy:
      • Ulcerated mass protruding from lumen
      • Nodular, clubbed, or fused folds
      • Overhanging, irregular, or thickened ulcer margins
  • H/pylori Testing
    • pylori serology and stool antigen testing
      • May be falsely negative if on concurrent PPI
    • Biopsy testing and histology from endoscopy
    • Urea Breath Test


Initial Management

  • Withdrawal of offending or contributing factors
    • Stop NSAIDs, smoking, EtOH, precipitant foods
  • Antisecretory therapy
    • (+) H. pylori Ulcer
      • Uncomplicated – 14 days
      • Complicated – up to 12 weeks
    • NSAID Induced
      • If stopping – 8 weeks
      • If continuing – indefinitely
    • Non-H.pylori, non-NSAID Ulcer
      • 4-8 weeks
    • PPIs out perform H2A
      • Esomeprazole (Nexium) – 20-40mg daily
      • Lansoprazole (Prevacid) – 15-30mg daily
      • Omeprazole (Prilosec) – 20-40mg daily
      • Pantoprazole (Protonix) – 20-40mg daily
    • High Risk Groups Requiring Indefinite Prophylaxis
      • > 2 cm ulcer on endoscopy and age > 50yo
      • Refractory H. pylori negative, NSAID negative ulcer
      • Failure to eradicate H. pylori
      • Frequently recurrent peptic ulcers (> 2 cases in 1 one)
      • Continued NSAID use
  • H. pylori Eradication
    • Risk factors for Macrolide resistance
      • Prior exposure to macrolide therapy
      • ≥ 15% clarithromycin local resistance rates
      • < 85% eradication rates with clarithromycin triple therapy
    • Initial Therapy
    • Salvage Therapy
      • 20% of patients will fail initial H. pylori eradication

References

  1. Sung JJ, Kuipers EJ, El-Serag HB. Systematic review: the global incidence and prevalence of peptic ulcer disease. Alimentary pharmacology & therapeutics. 2009; 29(9):938-46. [pubmed]
  2. Lin KJ, García Rodríguez LA, Hernández-Díaz S. Systematic review of peptic ulcer disease incidence rates: do studies without validation provide reliable estimates? Pharmacoepidemiology and drug safety. 2011; 20(7):718-28. [pubmed]
  3. Sonnenberg A. Temporal trends and geographical variations of peptic ulcer disease. Alimentary pharmacology & therapeutics. 1995; 9 Suppl 2:3-12. [pubmed]
  4. Thorat MA, Cuzick J. Prophylactic use of aspirin: systematic review of harms and approaches to mitigation in the general population. European journal of epidemiology. 2015; 30(1):5-18. [pubmed]
  5. García Rodríguez LA, Hernández-Díaz S. Risk of uncomplicated peptic ulcer among users of aspirin and nonaspirin nonsteroidal antiinflammatory drugs. American journal of epidemiology. 2004; 159(1):23-31. [pubmed]
  6. Gururatsakul M, Holloway RH, Talley NJ, Holtmann GJ. Association between clinical manifestations of complicated and uncomplicated peptic ulcer and visceral sensory dysfunction. Journal of gastroenterology and hepatology. 2010; 25(6):1162-9. [pubmed]
  7. Wilcox CM, Clark WS. Features associated with painless peptic ulcer bleeding. The American journal of gastroenterology. 1997; 92(8):1289-92. [pubmed]
  8. Paimela H, Paimela L, Myllykangas-Luosujärvi R, Kivilaakso E. Current features of peptic ulcer disease in Finland: incidence of surgery, hospital admissions and mortality for the disease during the past twenty-five years. Scandinavian journal of gastroenterology. 2002; 37(4):399-403. [pubmed]
  9. Malfertheiner P, Megraud F, O’Morain CA. Management of Helicobacter pylori infection-the Maastricht V/Florence Consensus Report. Gut. 2017; 66(1):6-30. [pubmed]
  10. Chiorean MV, Locke GR, Zinsmeister AR, Schleck CD, Melton LJ. Changing rates of Helicobacter pylori testing and treatment in patients with peptic ulcer disease. The American journal of gastroenterology. 2002; 97(12):3015-22. [pubmed]
  11. Yeomans ND, Tulassay Z, Juhász L. A comparison of omeprazole with ranitidine for ulcers associated with nonsteroidal antiinflammatory drugs. Acid Suppression Trial: Ranitidine versus Omeprazole for NSAID-associated Ulcer Treatment (ASTRONAUT) Study Group. The New England journal of medicine. 1998; 338(11):719-26. [pubmed]
  12. Duck WM, Sobel J, Pruckler JM. Antimicrobial resistance incidence and risk factors among Helicobacter pylori-infected persons, United States. Emerging infectious diseases. 2004; 10(6):1088-94. [pubmed]
  13. Chey WD, Leontiadis GI, Howden CW, Moss SF. ACG Clinical Guideline: Treatment of Helicobacter pylori Infection. The American journal of gastroenterology. 2017; 112(2):212-239. [pubmed]

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s