peptic ulcer disease

PUD

1. PUD

2. Peptic Ulcer Disease Definition The term peptic ulcer disease (PUD) refers to both duodenal ulcer and gastric ulcer disease. They cannot be distinguished definitively without endoscopy. The name is a misnomer based on the mistaken belief that they were caused by the protein-digesting enzyme pepsin.

3. Etiology PUD is most commonly caused by Helicobacter pylori. NSAIDs are the second most common cause because of their effect in inhibiting the production of the protective mucus barrier in the stomach. NSAIDs inhibit prostaglandins and prostaglandins produce the mucus.

4. Less common causes of peptic ulcers are: Burns Head trauma Crohn disease Gastric cancer Gastrinoma ( Zollinger -Ellison syndrome) Alcohol and tobacco do not cause ulcers. They delay the healing of ulcers . NSAIDs produce more bleeding than pain.

5. Presentation/"What Is the Most Likely Diagnosis?" PUD presents with recurrent episodes of epigastric pain that is described as dull, sore, and gnawing. Although the most common cause of upper GI bleeding is PUD, the majority of those with ulcers do not bleed. Tenderness and vomiting are unusual. You cannot answer PUD as the "most likely diagnosis“ based on symptoms alone. Duodenal ulcer (DU ) disease is more often improved with eating , whereas gastric ulcer (GU ) disease is more often worsened by eating . Hence, GU is associated with weight loss . You cannot definitively distinguish DU, GU, gastritis, and non-ulcer dyspepsia without endoscopy.

6. Diagnostic Tests Upper endoscopy is the most accurate test. Radiologic testing such as an upper GI series can detect ulcers, but cannot detect the presence of either cancer or H. pylori.

7. Helicobacter pylori Testing In those who are to undergo endoscopy, there is no point in doing noninvasive testing such as serology, breath testing, or stool antigen detection methods . Biopsy is the answer to "What is the most accurate test?" for H. pylori . Endoscopy is the only method of detecting gastric cancer. Cancer is present in 4% of those with GU but in none of those with DU.

8. Treatment PUD responds to PPi s in over 95% of cases, but will recur unless H. pylori is eradicated in those who are infected. DU is associated with H. pylori in more than 80% to 90% of cases, but GU is associated with H. pylori in 50% to 70% of cases.

9. H. pylori is readily eradicated with PPis in combination with 2 antibiotic s. The "best initial therapy" is a PPI combined with clarithromycin and amoxicillin . In those who do not respond to therapy, metronidazole and tetracycline can be used as alternate antibiotics. Adding bismuth to a change of antibiotics may aid in resolution of treatment-resistant ulcers. Retest with stool antigen or breath test to confirm cure of Helicobacter.

10. A 56-year-old woman comes to the clinic because her symptoms of epigastric pain from an endoscopically confirmed duodenal ulcer have not responded to severa weeks of a PPI, clarithromycin, and amoxicillin. What is the most appropriate next step in the management of this patient ? a. Refer for surgery b. Switch the PPI to ranitidine c. Abdominal CT scan d. Capsule endoscopy e. Urea breath testing f. Vagotomy g. Add sucralfate

11. Answer: E. If there is no response to DU therapy with PPis , clarithromycin, and amoxicillin,the first thought should be antibiotic resistance of the organism. Persistent H. pylori infection can be detected with several methods such as urea breath testing, stool antigen detection, or a repeat endoscopy for biopsy. It would be very hard to choose between these, and that is why they are not all given as choices in this question. Capsule endoscopy cannot detect H. pylori. Vagotomy and surgery were done more frequently in the past before we knew that H. pylori was the cause of most ulcers and we did not routinely eradicate it. H2 blockers and sucralfate add nothing to a PPI and have less efficacy, not more.

12. Treatment of Refractory Ulcers If the initial therapy does not resolve the DU, then detecting persistent H. pylori and switching the antibiotics to metronidazole and tetracycline is appropriate . For those with GU, a repeat endoscopy is done to exclude cancer as a reason for not getting better.

13. Treatment failure most often stems from: • Nonadherence to medications • Alcohol • Tobacco • NSAIDs Test for cure of H. pylori after treatment with stool antigen or breath test.

14. Gastric Ulcers Ultimately , the most important reason to scope a patient is to exclude GU as a cause of the pain because of the possibility of cancer. The only way to exclude cancer is with biopsy . You can test for H. pylori with noninvasive methods and treat it, but you cannot exclude gastric cancer noninvasively.

15. What Is Different about GU versus DU? • GU pain is more often worsened by food . • GU is routinely biopsied . • GU is associated with cancer in 4 %. • Routinely repeating the endoscopy to confirm healing is standard with GU

16. A 37-year-old male with a history of asthma and peptic ulcer disease presents to the emergency department with severe abdominal pain. He states the pain began suddenly this morning, is located in his upper abdomen, and is 10/10 in severity. On exam, his vitals are T: 38.3 deg C, HR: 100 bpm , BP: 118/90, RR: 10, SaO2: 100%. Guarding and rebound tenderness are observed on abdominal exam. An EKG is obtained as shown in Figure A and amylase/lipase levels are found to be 50/20, respectively. A chest radiograph is obtained as shown in Figure B. What is the most appropriate next step in management? FIGURES : A B 1. Activation of catheterization lab 2. Emergent surgical intervention 3. Abdominal CT scan with contrast 4. Abdominal ultrasound 5. Emergency endoscopy

17. Figure A is an EKG demonstrating normal sinus rhythm. Figure B is a chest radiograph demonstrating free air under the diaphragm indicative of viscous rupture. Illustration A is an endoscopic image of a perforated gastric ulcer. Illustration B is a graphic representation of a perforated gastric ulcer.

18. 2 DISCUSSION: This patient most likely presents with a perforated peptic ulcer as demonstrated by his chest radiograph demonstrating free intraperitoneal air under the diaphragm. Treatment is emergent surgical intervention. A peptic ulcer is an erosion of the mucosal lining of the stomach causing abdominal pain and discomfort. Peptic ulcer disease (PUD) is very common, with a lifetime risk of 10% in the population. Complications of PUD include rupture of an ulcer which results in severe abdominal pain and peritoneal signs on physical exam. Patients with peptic ulcer rupture will typically have normal EKGs, cardiac enzymes, and amylase/lipase. On chest radiograph, free air under the diaphragm indicates a viscous rupture - most commonly from a perforated ulcer in a patient with severe abdominal pain and a history of PUD. A ruptured peptic ulcer is a true surgical emergency and warrants emergent surgical intervention and repair.

19. Incorrect Answers: Answer 1: This patient has a normal EKG and a chest radiograph with free air indicating a perforated viscus making MI very unlikely. Thus, activation of catheterization lab should not occur. Answer 3: While an abdominal CT scan may be obtained in non-emergent cases of abdominal pain, patients with free air under the diaphragm have a perforated viscus until proven otherwise and require emergent operative repair. Answer 4: Abdominal ultrasound is not indicated in this patient due to the presence of a chest radiograph with free air indicating a perforated viscus . Answer 5: While endoscopy would demonstrate a perforated peptic ulcer, the diagnosis is already demonstrated with the chest radiograph. Thus, the patient should proceed immediately to the OR without further study.

20. A 53-year-old male presents to the emergency with severe abdominal pain and hematemesis. The patient’s history is significant for osteoarthritis, for which he has been taking ibuprofen for several years. He states he has had epigastric abdominal pain during meals for several months, but has never experienced pain like this. Vital signs are T 38C, HR 130, BP 100/55, RR 22, O2 saturation 99%. Physical exam reveals marked abdominal pain with rebound tenderness and involuntary guarding. Upright chest radiograph reveals free air under the right diaphragm. Which of the following is the most appropriate next step? Topic Review Topic 1. Intravenous octreotide 2. Exploratory laparotomy 3. Intravenous antibiotics and pantoprazole 4. Esophagogastroduodenoscopy (EGD) 5. Angiographic embolization

21. 3 DISCUSSION: The patient’s presentation is consistent with a perforated peptic ulcer. In addition to fluid resuscitation, the patient should receive intravenous (IV) antibiotics and a proton pump inhibitor (PPI) prior to surgical repair. Perforation is a known complication of peptic ulcer disease (PUD). Patients will complain of significant abdominal pain and may present with fever, hypotension, tachycardia, and signs of peritonitis (abdominal rigidity, rebound tenderness, hypoactive bowel sounds). An upright chest radiograph is often the first diagnostic step as free air can be visualized under the diaphragm; however, if air is not seen but clinical suspicion is high, further evaluation should be performed.

22. Incorrect answers: Answer 1: IV octreotide is useful in the management of esophageal variceal bleeding, but not indicated for NSAID-induced PUD. Answer 2: Surgical repair of the perforation will be required, but IV antibiotics and PPI should be administered prior. Answer 4: EGD can diagnose PUD, but with peritonitis, free air and the clinical history, surgical therapy after IV antibiotics and PPI is more appropriate. Answer 5: Embolization is useful in cases of uncontrollable bleeding, but is not clinically indicated in perforated PUD otherwise.

23. A 75-year-old male presents with a 1-month history of severe abdominal and epigastric pain. He states that his pain improves with meals but worsens approximately one hour after eating. He has a history of osteoarthritis, which he treats with NSAIDs; he has increased his dose for the past 3 months due to increased pain. Vital signs are stable and within normal limits. Endoscopy is performed, and the results are shown in Figure A. What is the most common complication of this patient's condition? FIGURES : A 1. Perforation 2. Hemorrhage 3. Obstruction 4. Intractable pain 5. Strictures

24. 2 DISCUSSION: This patient has epigastric and abdominal pain that improves immediately after eating, and he is found by endoscopy to have a duodenal ulcer. The most common complication of duodenal ulcers is hemorrhage . Duodenal ulcers are caused by damage to the intestinal mucosa. Duodenal ulcers are often due to acid hypersecretion and are associated with H. pylori in over 90% of cases. Other causes include NSAID use, corticosteroids, tobacco, and alcohol. Duodenal ulcers typically present with chronic, dull, burning epigastric pain that improves with meals but worsens 1 to 3 hours afterwards. Complications of duodenal ulcers include hemorrhage , obstruction, intractable pain, and perforation.

25. A 50-year-old male presents to the emergency with abdominal pain. He reports he has had abdominal pain associated with meals for several months and has been taking over the counter antacids as needed, but experienced significant worsening pain one hour ago in the epigastric region. The patient reports the pain radiating to his shoulders. Vital signs are T 38, HR 120, BP 100/60, RR 18, SpO2 98%. Physical exam reveals diffuse abdominal rigidity with rebound tenderness. Auscultation reveals hypoactive bowel sounds. Which of the following is the next best step in management? Topic Review Topic 1. Abdominal ultrasound 2. Chest radiograph 3. Emergent exploratory laparotomy 4. 12 lead electrocardiogram 5. Admission and observation

26. 2 DISCUSSION: The patient’s presentation is worrisome for a peptic ulcer perforation. The next best step in evaluation is upright chest radiograph to look for pneumoperitoneum (Illustration A). Peptic ulcer disease is one of the most common causes of gastrointestinal tract perforation in adults. Patients will complain of significant abdominal pain and may present with fever, hypotension, tachycardia, and signs of peritonitis (abdominal rigidity, rebound tenderness, hypoactive bowel sounds). An upright chest radiograph is often the first diagnostic step as free air can be visualized under the diaphragms; however, if air is not seen but clinical suspicion is high, further evaluation should be performed with CT or ultrasound.

27. Illustration A: CXR showing pneumoperitoneum , i.e. free air under the diaphragm.

28. Incorrect answers: Answer 1: Abdominal ultrasound is most commonly used in evaluation of cholelithiasis and other biliary tract pathologies. It can be used to evaluate for free air and fluid, but chest radiography is preferred as a first step. Answer 3: Surgery may be required, but assessment of pneumoperitoneum is required first. Answer 4: Electrocardiogram should be performed but does not aid in diagnosis. Answer 5: The patient will require intervention to repair the suspected perforation.

29. 48-year-old gentleman presents to his primary care physician complaining of epigastric pain and excessive belching. He states that he has recently been having black, tarry stools. An upper endoscopy is performed and reveals a gastric ulcer. How would food most likely affect this patient? Topic Review Topic 1. All food would make his pain better 2. All food would make his pain worse 3. All food will have no effect on his pain 4. Acidic foods would improve his pain 5. Basic foods would improve his pain

30. 2 DISCUSSION: The patient in the above vignette has gastric ulcer as per the upper endoscopy. Pain from gastric ulcers worsen with food intake (as compared to duodenal ulcers that improve with food intake). Peptic ulcer disease is a general term describing the damage to the gastric or duodenal mucosa. Gastric ulcers are not caused by acid hypersecretion as some typically think. Instead, it is the duodenal ulcers that are caused by acid hypersecretion and H. pylori is found in >90% of duodenal ulcers. It is classic for gastric ulcers to present with worsening pain upon ingestion of foods. Conversely, duodenal ulcers improve with food intake.

31. Incorrect Answers: Answer 1: Duodenal ulcers improve with food ingestion. Answer 3: Gastric ulcers are usually made worse with food ingestion. Answers 4,5: Gastric ulcers are usually made worse with food ingestion, regardless of the type of food ingested.

32. A 75-year-old female with a long history of debilitating osteoarthritis presents to clinic complaining of gnawing abdominal pain. She has been unable to eat anything substantial for days, as food seems to aggravate the pain. Review of systems is positive for darker stools. Vital signs are stable. Abdominal exam is notable for tenderness to palpation along and just below the epigastrium, without rebound or guarding. What is the most likely diagnosis? Topic Review Topic 1. Duodenal ulcer secondary to H. pylori 2. Gastric ulcer secondary to chronic NSAID use 3. Lower gastrointestinal bleed 4. Squamous cell carcinoma of the esophagus 5. Perforated peptic ulcer

33. 2 DISCUSSION: This patient with melena and abdominal pain has peptic ulcer disease secondary to chronic NSAID use for osteoarthritis. Because her pain is worse with eating and NSAIDS are likely implicated, a gastric ulcer is more likely than duodenal ulcer. Gastric ulcers often occur in older patients. H. pylori and chronic NSAID use are the most common causes. In contrast, almost 100% of duodenal ulcers are due to H. pylori infection. Pain from Gastric ulcers is often Greater with meals, while pain from Duodenal ulcers often Decreases with meals. Potential complications include bleeding, penetration into the pancreas, obstruction, and perforation.