Peptic ulcer disease

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

  • Consult surgery
  • Antibiotics to cover abdominal flora
  • IVF


Non-Perforated

  • Stop NSAIDs and ETOH
  • PPI
    • Generally heal ulcers faster than H2 blockers[2]
    • Omeprazole 20-40mg QD
  • H2 blocker
    • Famotidine 20-40mg QD
    • 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

  • Normally outpatient management, unless complication (see below)


Red Flags

Any of the following suggest need for endoscopy referral:

  • Age >55yr
  • Unexplained weight loss
  • Early satiety
  • Persistent vomiting
  • Dysphagia
  • Anemia or GI bleeding
  • Abdominal mass
  • Persistent anorexia
  • Jaundice


Complications

  • Perforation (see above)
  • Hemorrhage
    • Upper GI Bleeding
  • Obstruction, due to:
    • Scarring of gastric outlet
    • Edema due to active ulcer


See Also

  • Epigastric abdominal pain


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.
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