PANCE Blueprint GI and Nutrition (9%)

Gastric ulcer: Patient will present with → abdominal discomfort that is worse with meals and gets better an hour or so later after eating.

Duodenal ulcer: Patient will present as → a 62-year-old female with complaints of epigastric pain and belching, which improves when she eats food but gets worse a few hours after her meal. She said he has noticed a change in the color of her stool.

PUD is an ulcer of the upper GI tract mucosa involving the proximal duodenum (duodenal ulcer~90%) and distal stomach (gastric ulcer~10%)

Duodenal ulcer (food classically decreases pain think Duodenum = Decreased pain with food)

• Duodenal ulcers are more than twice as common as gastric ulcers
• Duodenal ulcers are most commonly caused by H. pylori (95%)
• Pts typically present with epigastric pain that is better postprandial
• Usually located in the anterior duodenum ⇒ when present in the posterior duodenum can lead to bleeding from the gastroduodenal artery or cause acute pancreatitis
• Rarely, it can be caused by Zollinger-Ellison syndrome (this is a gastrinoma; a tumor of the pancreas that causes the stomach to produce too much gastrin with subsequent acid secretion leading to ulcer formation. Diagnosed with gastrin levels >200 pg/mL)

10 mm duodenal ulcer in a patient with GI bleeding

Gastric ulcer (food classically causes pain)

• Gastric ulcers are most commonly caused by H. pylori. It can also be caused by NSAIDs, acid reflux, smoking
• Pain is described as gnawing or burning and usually radiates to the back
• Patients typically present with epigastric pain that is worse with food (postprandial)
• It is most commonly found at the lesser curvature of the antrum

Esophagogastroduodenoscopy Image of gastric ulcers in the antrum

PUD is the MC cause of non-hemorrhagic GI bleed, typically presenting as hematemesis (either red blood or coffee-ground emesis), or melena (black, tarry stool

Upper endoscopy is the most accurate diagnostic test for peptic ulcer disease

• Biopsy for H. pylori should be obtained in all patients undergoing upper endoscopy for PUD unless contraindicated
• Biopsy of ulcers for benign-appearing ulcers is not recommended ⇒ all ulcers with malignant features should be biopsied
• Ruptured ulcer - elevated serum amylase and free air under the diaphragm seen on upright film make the diagnosis

All patients with peptic ulcers should receive antisecretory therapy with a proton pump inhibitor (PPI) (e.g., omeprazole 20 to 40 mg daily or equivalent) for 4-8 weeks

• Patients with evidence of H. pylori on biopsy should receive eradication therapy
  • Triple therapy: PPI + Amoxicillin 1g PO BID or Metronidazole 250 mg QID + Clarithromycin 500 mg PO BID (think baseball "CAP" = Clarithromycin + Amoxicillin + PPI)
  • Quadruple therapy: PPI + Bismuth subsalicylate 524 mg 4 times a day + Metronidazole 250 mg 4 times a day + Tetracycline 500 mg 4 times a day
    • Best initial therapy in areas where the clarithromycin resistance rate is > 15%
  • In patients with active bleeding, a negative biopsy result does not exclude H. pylori, and a breath test or a stool antigen test for H. pylori should be performed to confirm a negative result
  • In patients who receive treatment for H. pylori, eradication should be confirmed four or more weeks after the completion of therapy

Discontinue nonsteroidal anti-inflammatory drugs (NSAIDs)

• Patients with NSAID-associated ulcers should be treated with a PPI for a minimum of eight weeks
• PPI therapy for four to eight weeks in patients with H. pylori-negative ulcers that are not associated with NSAID use
• Zollinger-Ellison syndrome: PPI and resect the tumor
• Patients with duodenal ulcers who have been treated do not need further endoscopy unless symptoms persist at four weeks or recur

In the event of rupture - immediate surgical intervention is required for treatment.