Peptic Ulcer Disease

2 main causes:

  1. Helicobacter pylori infection
    1. Causes inflammation of the mucosal lining of the stomach, depleting the layer of protective alkaline mucus and altering gastric acidity
  2. Nonsteroidal anti-inflammatory drugs (NSAIDs)
    1. Inhibits prostaglandin synthesis, reducing the production of protective alkaline mucus

Presentation

  • Epigastric pain - usually post-prandial and can be relieved by eating
  • Bloating
  • Weight loss
  • Nausea (uncommon)

History

  • Enquire about use of NSAIDs
  • Smoking history
  • Past medical history of peptic ulcer disease

Differentials

  • Oesophageal cancer (assess for alarm symptoms: weight loss, bleeding, anaemia, vomiting, early satiety, dysphagia or family history)
  • Stomach cancer
  • Gastro-oesophageal Reflux disease (absence of ulcers on endoscopy)
  • Gastroparesis

Bedside tests

FBC- may show evidence of iron-deficiency anaemia

Laboratory investigations

H.Pylori test using either:

  • Urea breath test (unless they have received a proton pump inhibitor [PPI] in the past 14 days or an antibiotic in the past 28 days)
  • Stool antigen test (unless they have received a PPI in the past 14 days or an antibiotic in the past 28 days)
  • Laboratory serology testing (where the performance of the test has been locally validated), unless they have previously been treated for H.pylori infection

Management

++++First Line- Eradication therapy

If H.Pylori is present

  • 7-day, twice-daily course of treatment with:
  1. PPI (lansoprazole 30mg, omeprazole 20mg, esomeprazole 20mg)
  2. Amoxicillin 1g
  3. Clarithromycin 500mg (or metronidazole)

If H.Pylori is not present and ulcer is due to NSAID/aspirin use

  • Offer full-dose PPI e.g Esomeprazole, lansoprazole, omeprazole OR an H2 receptor antagonist therapy for 4 to 8 weeks to people who have tested negative for H. pylori who are not taking NSAIDs
  • Stop NSAID use and offer alternative analgesia

Follow up

  • Offer people with gastric ulcers and H. pylori a repeat endoscopy 6-8 weeks after beginning treatment
  • Offer people with peptic ulcer (gastric or duodenal) and H. pylori retesting 6-8 weeks after beginning treatment
    • Perform re-testing for H. pylori using a carbon-13 urea breath test

Complications

  • Erosion of blood vessels, causing:
    • Acute massive haemorrhage
    • Chronic bleeding, resulting in anaemia
  • Perforation of the gastrointestinal tract, causing peritonitis.
  • Development of strictures and pyloric stenosis due to chronic inflammation from ulcers

Prognosis

  • For peptic ulceration associated with Helicobacter pylori infection, eradication markedly reduces the risk of recurrent ulceration
  • Lifetime risk of recurrence for gastric ulcers is 60% if the person remains H. pylori positive, but 5% following eradication of H. pylori.
  • Lifetime risk of recurrence for duodenal ulcers is 80% if the person remains H. pylori positive, but 5% following eradication of H. pylori.
  • For peptic ulceration associated with the use of NSAIDs, stopping the NSAID or prescribing concomitant gastroprotection (with a proton pump inhibitor or H2-receptor antagonist) reduces the risk of recurrence of dyspepsia symptoms
Unless otherwise stated, the content of this page is licensed under Creative Commons Attribution-ShareAlike 3.0 License