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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

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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]
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