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 with → abdominal discomfort that improves with meals and gets worse an hour or so later after eating.
A peptic ulcer is an erosion in a segment of the GI mucosa (versus gastritis which is inflammation), typically in the stomach (gastric ulcer) or the first few centimeters of the duodenum (duodenal ulcer), that penetrates through the muscularis mucosae
Nearly all ulcers are caused by Helicobacter pylori infection or NSAID use. Symptoms typically include burning epigastric pain that is often relieved by food
- Zollinger-Ellison syndrome (gastrinoma) is the result of an unregulated release of gastrin resulting in gastric acid hypersecretion. Up to 50% of patients complain of diarrhea along with peptic ulcer disease. diagnosed with serum gastrin levels (> 150 pg/mL is suggestive - > 200 pg/mL is diagnostic)
- Cigarette smoking is a risk factor for the development of ulcers and their complications. Also, smoking impairs ulcer healing and increases the incidence of recurrence
Pain with food = gastric ulcer
Pain after food = duodenal ulcer
Persistent or ↑ symptoms after PPI = Look for H.Pylori
- A biopsy is the gold standard for diagnosis of H.Pylori – serology is not reliable
- The second most reliable is urea breath test and fecal antigen testing
Treatment for H.Pylori: PPI + Amoxicillin 1g PO BID + Metronidazole or Clarithromycin 500 mg PO BID
- Think baseball "CAP" = Clarithromycin + Amoxicillin + PPI
- 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
|Peptic ulcers are caused by an erosion of the mucosal wall of the gastrointestinal tract. These ulcers develop when excess hydrochloric acid and digestive enzymes (pepsin) disrupt the gastric mucosal barrier, causing breakdown. A bacteria called Helicobacter pylori (H. pylori) may also contribute to peptic ulcer formation; however, not everyone who is infected with this bacteria will develop an ulcer. Patients with this condition may present with abdominal pain, heartburn, GI distress, black, tarry stools, and weight loss.|
|Zollinger-Ellison syndrome (ZES) is caused by gastrin-secreting tumors, known as gastrinomas. The sequelae of this disease are the result of excess gastric acid production, which leads to abdominal pain, heartburn, diarrhea and ulcers in patients. These ulcers present most commonly in the proximal duodenum, and less commonly in the distal duodenum and jejunum. Furthermore, these are usually solitary ulcers. Patients may present with gastrointestinal bleeding as well. Abdominal pain and heartburn occur secondary to gastroesophageal reflux disease (GERD), which develops in roughly 50% of patients with Zollinger-Ellison syndrome. The gastrinomas of this disease can be sporadic and can occur without any other disease present. However, an important correlation of this disease is that 25% of cases are associated with multiple endocrine neoplasia type 1 (MEN 1).|
|Helicobacter pylori is a gram-negative bacillus with multiple flagella that causes gastritis and peptic ulcer disease (PUD). H. pylori are the most common cause of gastric and duodenal ulcers. It survives in the stomach's acidic environment by producing urease, which converts urea to ammonia and makes the stomach more alkaline. It disrupts the stomach's mucous layer which leaves the underlying tissue susceptible to damage and also elicits an inflammatory reaction resulting in chronic gastritis. As a result, long term complications include gastric adenocarcinoma and MALT lymphoma. Detection of H. pylori infection is made by IgG serology, stool antigen assay, urease positive breath test or an endoscopic biopsy. Treatment is a combination of two antibiotics, typically clarithromycin and either amoxicillin or metronidazole, as well as a proton-pump inhibitor (PPI).|
|Proton pump inhibitors are a class of drugs that act directly on the H+/K+/ATPase pump to prevent the secretion of acid. They are indicated for GERD, peptic ulcer disease, treatment of gastritis and for gastrinomas, such as Zollinger-Ellison syndrome. These drugs are easy to remember, as they share a common suffix, "prazole," exemplified by the medication omeprazole.
Common side effects of these medications include hip fracture, as this drug class decreases calcium absorption, as well as pneumonia, due to bacterial overgrowth in a less acidic environment.
|Sucralfate (Carafate) is an antiulcer agent used in patients with duodenal ulcers. This medication works by creating a barrier that protects existing ulcers from stomach acid and pepsin, allowing the ulcer(s) to heal. Patients should be instructed to take sucralfate on an empty stomach and at least two hours before or after a meal. An oral suspension may be recommended for patients with difficulty swallowing large pills.|
|H2 blockers are antagonists at the histamine H2 receptor, which are found within the parietal cells of the stomach. These medications can be recalled easily, because of the common suffix found in their drug names, "itidine." These drugs may help to treat GI disorders including indigestion and heartburn (GERD), and promote the healing of ulcers. This drug class exerts its action by blocking histamine H2 receptors in parietal cells of the stomach, leading to reduced acid secretion.
Particular medications within this drug class causing notable side effects are ranitidine and cimetidine, which both cause decreased creatinine clearance via inhibition of tubular secretion. Cimetidine, however, crosses the blood-brain barrier and may lead to headache, dizziness and confusion. Cimetidine is also an anti-androgen, which works as a competitive antagonist at DHT receptors. Furthermore, it is a potent inhibitor of the cytochrome P450 enzyme system, and may decrease the metabolism of other medications.
Gastric ulcer causes abdominal discomfort that is worse with meals and gets better an hour or so later after eating.
RUQ pain and + Murphy's sign
Acute pancreatitis can cause epigastric pain which is usually sudden in onset and gradually intensifies in severity until reaching a constant ache. Patient would usually present at the emergency looking toxic especially when severe.
A proton pump inhibitor
Pain from esophagitis is usually retrosternal. Most patients complain of heartburn due to acid reflux. There is no periodicity and association with food.
Acute pancreatitis can cause epigastric pain which is usually sudden in onset and gradually intensifies in severity until reaching a constant ache. Patient would usually present at the emergency looking toxic especially when severe. There is no association with chronic NSAID use.
Peptic ulcer disease
Gastroesophageal reflux disease
GERD presents with heartburn which has no periodicity, and regurgitation.
Upper gastrointestinal endoscopy
Double-contrast barium enema
Double-contrast barium enema is not as sensitive as endoscopy for establishing a diagnosis of small ulcers (<0.5cm). It also does not allow for obtaining a biopsy.
Chest radiograph may be useful to detect free abdominal air when perforation is suspected. It cannot diagnose PUD.
None of the above
superior acid suppression
faster healing rates
safe for use in hepatically impaired patients
faster symptom relief
lower and less frequent dosing requirement
stool antigen test
urea breath test
enzyme-linked immunosorbent assay (ELISA) serology
Steiner stain of gastric biopsy specimen