Approach to the management of peptic ulcer disease

dr anjani k jha,resident int medicine,nepal,nomc

1. Approach to the management of Peptic U lcer D isease By: Dr. Anjani kumar jha 1 st year resident Internal medicine 2076/07/25

2. Introduction A peptic ulcer is defined as disruption of the mucosal integrity of the stomach and or duodenum leading to a local defect or excavation due to active inflammation. Although burning epi -gastric pain exacervated by fasting and improved with meals is a symptoms complex associated with PUD, it is now clear that more than 90% patients with this symptom complex (dyspepsia) do not have ulcers and that the majority patients with peptic ulcers may be asymptomatic. 11/10/2019 By Dr. Anjani kumar jha 2

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10. Incidence The prevalence of peptic ulcer 0.1 – 0.2 % is decreasing in many western countries as a result of widespread use of H.pylori eradication therapy but remains high in developing countries. The male to female ratio for duodenal ulcer varies from 5:1 to2:1 while that for gastric ulcer is 2:1 or less. GU and DU coexists in 10% of patients. 11/10/2019 By Dr. Anjani kumar jha 10

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12. Etiology Helicobacter pylori, a spiral, gram negative , urease producing bacillus, is responsible for at least half of all PUD and the majority of ulcers that are not due to NSAIDs. PUD can develop in 15-25%of chronic NSAID and aspirin users. Past history of PUD, age >60 yrs , concomitant corticosteroids or anticoagulant therapy, high dose or multiple NSAID therapy and presence of serious comorbid medical illness increase risk for PUD . 11/10/2019 By Dr. Anjani kumar jha 12

13. Contd.. A gastrin secreting tumor or gastrinoma accounts for <1% of all peptic ulcers. Gastric cancer or lymphoma may manifest as a gastric ulcer. When none of these etiologies are evident ,PUD is designated idiopathic. Cigarette smoking doubles the risk for PUD; it delays healing and promotes recurrence. 11/10/2019 By Dr. Anjani kumar jha 13

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15. Clinical features Epi -gastric pain described as burning or gnawing discomfort can present in both DU and GU. The discomfort is also described as an ill defined, aching sensation or as hunger pain. The typical pain pattern in DU occurs 90min. To 3 hrs. after a meal and frequently relieved by antacids or food . Pain that awakes the patient from sleep between midnight and 3am is the most discriminating symptoms . 11/10/2019 By Dr. Anjani kumar jha 15

16. Contd.. The pain pattern in GU patients may actually be precipitated by food. Nausea and weight loss occur more commonly in GU patients. Endoscopy detects ulcer in less than 30% of patients who have dyspepsia. In physical examination, epi -gastric tenderness is the most frequent finding in patients with GU or DU. Tachycardia and orthostasis suggest dehydration secondary to vomiting or active GI blood loss . A severely tender, board like abdomen suggests a perforation. Presence of a succusion splash indicates retained fluid in the stomach suggesting GOO. 11/10/2019 By Dr. Anjani kumar jha 16

17. Complications GI bleeding GOO Perforation Pancreatitis 11/10/2019 By Dr. Anjani kumar jha 17

18. Differential diagnosis Functional dyspepsia or essential dyspepsia which refers to the group of heterogenous disorders charcterised by upper abdominal pain without the presence of an ulcer. GERD Proximal GI tumors Vascular disease Pancreatico-billiary disease(chronic pancreatitis ) Gastro-duodenal cron’s disease. ACS Acute cholecystitis Cholangitis Gastritis Gall stone Esophagitis 11/10/2019 By Dr. Anjani kumar jha 18

19. Investigations Endoscopy provides the most sensitive and specific approach for examining the upper GI tract . Gastric ulcer can occasionally be malignant and therefore most always be biopsied and followed up to ensured healing. Patient should be tested for H. pylori infection. 11/10/2019 By Dr. Anjani kumar jha 19

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31. Monitoring/ follow up Repeat EGD or upper GI series should be performed 8-12 weeks after initial diagnosis of all gastric ulcers to document healing; repeat endoscopic biopsy should be considered for non-healing ulcers to exclude the possibility of a malignant ulcer. Duodenal ulcers are almost never malignant; therefore ,documentation of healing is unnecessary in the absence of symptoms. 11/10/2019 By Dr. Anjani kumar jha 31

32. References Harrisons principles of internal medicine , 20 th edition. Davidson principles and practice of medicine , 23 rd edition. Washington manual of medical therapeutics ,35 th edition. 11/10/2019 By Dr. Anjani kumar jha 32

33. Thank you !!! 11/10/2019 By Dr. Anjani kumar jha 33