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Peptic Ulcer Disease

From Mediwikis


Overview[1][2]

Definitions

Ulcer: a break in an epithelial surface

Peptic ulcer: an ulcer in the digestive tract caused by digestion of the mucosa by pepsin and acid

Examples

Common: gastric ulcer, duodenal ulcer

Uncommon: oesophageal ulcer, jejunal ulcer

Causes & Risk Factors[2][3][4][5][6]

  • Helicobacter pylori infection
  • various drugs:
    • NSAIDs (inhibit prostaglandin synthesis, thereby destroying mucosal defence mechanisms)
    • corticosteroids (immunosuppressive)
    • selective serotonin reuptake inhibitors
  • smoking
  • age
  • physical stress e.g. neurosurgery or burns

Clinical Features[2][3][7]

Signs & Symptoms

  • nausea
  • dyspepsia
  • localized epigastric pain and tenderness

Gastric vs Duodenal Ulcers

Ulcer type gastric duodenal
Radiation of pain none back
Timing of pain post-prandial - pre-prandial

- nocturnal

Relieving factors antacids - eating

- drinking milk

Most common cause NSAIDs H. pylori
Male:female incidence 3:1 5:1
Peak age of incidence 50y 30y

Complications

Investigations & Diagnosis[2][3]

  • oesophagoduodenogastroscopy (OGD) (upper GI endoscopy)
    • barium meal if OGD contraindicated
    • ulcer biopsies for histology
    • ulcer brushings for cytology
  • H. pylori test
    • urea breath test
    • biopsies from OGD

Management[2][3][8]

Note that there is not sufficiently strong evidence comparing surgical and medical management options[9]

Conservative

  • stop smoking
  • reduce alcohol intake
  • reduce stress

Medical

  • to reduce gastric acid secretion:
    • proton pump inhibitor (PPI) e.g. omeprazole 20 mg OD
    • H2 blockers e.g. ranitidine 150 mg BD
  • antacid e.g. colloidal bismuth
  • triple therapy for H. pylori e.g. omeprazole 20 mg + amoxicillin 1g + clarithromycin 500 mg BD for 1 week

Surgical

Type of surgery elective emergency
Procedure highly selective vagotomy various*
Indication medical treatment not tolerated complications

*Haemorrhage may be controlled endoscopically by adrenaline injection, diathermy, laser coagulation or heat probe.

*Perforation may be managed medically with IV antibiotics, but most patients have reparative surgery.

*Pyloric stenosis is treated with endoscopic balloon dilatation followed by maximal acid suppression.

References

  1. Martin EA (ed.). Concise Medical Dictionary. 8th ed. Oxford: Oxford University Press, 2010.
  2. 2.0 2.1 2.2 2.3 2.4 Hawkey CJ, Atherton JC. Peptic Ulcer. In: Hawkey CJ et al (eds.). Textbook of Clinical Gastroenterology and Hepatology. 2nd ed. Oxford: Blackwell Publishing, 2012, 219-233.
  3. 3.0 3.1 3.2 3.3 Longmore M et al. Oxford Handbook of Clinical Medicine. 9th ed. Oxford: Oxford University Press, 2014.
  4. McLatchie G, Borley N, Chikwe J (eds.). Oxford Handbook of Clinical Surgery. 4th ed. Oxford: Oxford University Press, 2013.
  5. Dall M et al. There is an association between selective serotonin reuptake inhibitor use and uncomplicated peptic ulcers: a population-based case-control study. Ailment Pharmacol Ther 2010;32(11-2):1383-91.
  6. Guslandi M. Steroid ulcers: Any news? World J Gastrointestin Pharmacol Ther 2013;4(3):39-40.
  7. Sadowski DC et al. Five Things to Know About... Dyspepsia. CMAJ 2015;187(4):doi:10.1503/cmaj.141606.
  8. Ford CA et al. Eradication Therapy in Helicobacter pylori Positive Peptic Ulcer Disease: Systematic Review and Economic Analysis. American Journal of Gastroenterology 2004;99:1833-55.
  9. Gurusamy KS, Pallari E. Medical versus surgical treatment for refractory or recurrent peptic ulcer. Cochrane Database of Systematic Reviews 2016, Issue 3. Art. No.: CD011523. DOI: 10.1002/14651858.CD011523.pub2<http://dx.doi.org/10.1002/14651858.CD011523.pub2>