PEPTIC ULCER DISEASE (PUD)
I. Definition
A. A gastrointestinal ulcer is a loss of enteric surface epithelium that extends deeply enough to penetrate the muscularis mucosae.
B. PUD refers to a chronic disorder in which the patient has a lifelong underlying tendency to develop mucosal ulcers at sites that are exposed to peptic juice (i.e., acid and pepsin).
1. The most common locations are the duodenum and the stomach.
2. Ulcers may also occur in the esophagus, jejunum, and ileum, and at gastroenteric anastomoses.
II. Etiology
A. Helicobacter pylori (H. pylori) is present in more than 70% to 75% of duodenal ulcers; it occurs at a lower rate with gastric ulcers but is found in most gastric ulcers in which NSAIDs cannot be implicated.
B. An imbalance exists between mucosal defense mechanisms (protective factors) and mucosal damaging mechanisms (aggressive factors).
1. Protective factors
a. Mucosal barrier (bicarbonate and gastric mucus)
b. Sufficient blood supply to gastric mucosa and submucosa
c. Competent sphincters (pyloric and lower esophageal sphincter [LES]), which prevent bile salt reflux into the stomach and the esophagus
d. Certain medications
i. H2 blockers
ii. Antacids
iii. Sucralfate (Carafate)
iv. Colloidal bismuth suspension
vi. Misoprostol (Cytotec)
vii. Omeprazole (Prilosec)
2. Aggressive factors
a. Gastric acid
b. Pepsin
c. Bile acids
d. Decreased blood flow to gastric mucosa
e. Incompetent sphincters
f. Various medications
i. Aspirin
ii. NSAIDs
iii. Glucocorticoids
g. Cigarette smoking
h. Gastrinoma
i. Stress (especially posttraumatic)
j. Alcohol
k. Impaired proximal duodenal bicarbonate secretion
l. H. pylori infection
III. Risk factors
A. Highly associated
1. Smoking more than than ½ pack of cigarettes per day
2. Drugs (NSAIDs)
3. Family history
4. Zollinger-Ellison syndrome (condition caused by non–insulin-secreting tumors of the pancreas, which secrete excess amounts of gastrin)
B. Possibly associated
1. Corticosteroids
2. Stress
C. Low association or no association
1. Spices
2. Alcohol
3. Caffeine
4. Acetaminophen
IV. Types of peptic ulcers
A. Duodenal ulcers
1. In all, 90% to 95% occur in the first portion of the duodenum.
2. Four times more common than gastric ulcers
3. For men, 10% lifetime prevalence; 5% for women
4. New cases annually: 200,000 to 400,000
5. Most common age range is 25 to 55 years.
B. Gastric ulcers
1. Most commonly seen in the lesser curvature of the stomach near the incisura angularis
2. New cases annually: 87,500
4. Peak age of incidence: 55 to 65 years (rare before age 40)
V. Subjective findings
A. Duodenal ulcers
1. Epigastric pain (“gnawing,” “aching,” “hunger-like”) occurs 1 to 3 hours after eating. The pain is rhythmic and periodic.
2. Nocturnal pain that awakens a patient from sleep
3. Usually relieved by antacid or food ingestion
4. Heartburn (suggests reflux disease)
5. Epigastric tenderness: usually midline or right of midline
B. Gastric ulcers
1. Epigastric pain similar to that associated with duodenal ulcers and also rhythmic and periodic
2. Pain is not usually relieved by food.
3. Food may precipitate symptoms.
4. Nausea and anorexia
VI. Physical findings
A. Often unremarkable
B. Patient may have epigastric tenderness.
1. At or to the left of the midline with gastric ulcer
2. Located 1 inch or farther to the right of midline with duodenal ulcer
C. Signs and symptoms of shock from acute or chronic blood loss
D. Nausea and vomiting if the pyloric channel is obstructed
E. Boardlike abdomen and rebound tenderness in the event of perforation
F. Hematemesis or melena if the ulcer is bleeding
VII. Laboratory studies
A. Laboratory findings do not play a major role in diagnosing PUD but may assist the clinician in defining an underlying disorder or complication.
B. Laboratory studies are typically normal in uncomplicated disease.
C. For detection of H. pylori:
1. Histopathology (endoscopic biopsy)—gold standard
2. Urea breath test
a. Positive tests implies active infection.
b. More expensive than serum and stool tests
c. Proton pump inhibitors (PPIs) may cause false-negative results and should be withheld for at least 7 days before testing is done.
3. Serum H. pylori antibody test
a. Positive test does not necessarily imply an active infection; it may reflect previous infection.
4. Stool antigen for H. pylori
a. Detects active infection by measuring fecal excretion of H. pylori antigens
b. Good test to use to assess whether treatment has been successful
c. PPIs may cause false-negative results and should be withheld for at least 7 days before testing is done.
E. Leukocytosis suggests ulcer penetration or perforation.
F. Elevated serum amylase level with severe epigastric pain suggests possible ulcer penetration into the pancreas.
G. Fasting serum gastrin levels to identify Zollinger-Ellison syndrome
VIII. Diagnostics
A. Upper GI barium studies
1. For uncomplicated dyspepsia
2. Those diagnosed with gastric ulcers should undergo endoscopy after 8 to 12 weeks of treatment to distinguish benign from malignant ulcers.
B. Endoscopy
1. Highest accuracy rate (90% to 95%)
2. Identifies superficial and very small ulcers
3. Biopsy may be performed.
4. Electrocautery of any bleeding ulcers can be carried out.
5. Gastric pH can be measured in suspected gastrinoma.
6. Esophagitis, gastritis, or duodenitis can be diagnosed.
7. H. pylori can be detected.
8. Higher cost than barium studies
IX. Complications of PUD
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A. GI bleeding (20% of cases)
1. Clinical manifestations
a. Hematemesis
b. Melena
c. Hematochezia
d. “Coffee ground” emesis
2. Physical examination
a. Pallor
b. Tachycardia
c. Hypotension
d. Diaphoresis
3. Laboratory findings
a. Decreased hematocrit due to bleeding or hemodilution from IV fluids
b. BUN may rise owing to absorption of blood nitrogen from the small intestine and as the result of prerenal azotemia.
4. Diagnostics: endoscopy after the patient has stabilized
5. Management
a. In approximately 80% of cases, bleeding stops spontaneously within a few hours after admission to the hospital.
b. IV hydration with normal saline
c. Blood transfusion as required
d. Continuous IV infusion of H2 blockers at a dose adequate to maintain gastric pH above 4
e. Vasopressin (Pitressin) and IV octreotide (Sandostatin) should not be used for bleeding ulcers.
f. Surgery if bleeding persists
C. Gastric outlet obstruction (2% of cases)
1. Caused by edema or narrowing of the pylorus or duodenal bulb
2. Subjective findings:
a. Early satiety
b. Nausea
c. Vomiting of undigested food
d. Epigastric pain unrelieved by food or antacids
e. Weight loss
3. Physical examination findings:
a. “Succussion splash” may be audible on physical examination, caused by large amounts of air and fluid in the stomach.
b. Nasogastric aspiration may return a large amount (more than 200 ml) of foul-smelling fluid.
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