inpatient / gastroenterology
Peptic Ulcer Disease (PUD) and H. Pylori
# Peptic Ulcer Disease
# H Pylori
Assessment:
-- History: ***timing of pain, NSAID or steroid use, alcohol, smoking, stress; Alarm - progressive dysphagia, weight loss, vomiting, suspected GI bleed, FHx upper GI malignancy
-- Clinical: *** dull aching epigastric pain, N/V, diarrhea, flushing
-- Exam: *** abdominal pain, evidence of peritonitis
-- Data: ***
-- Etiology/DDx: *** NSAIDs, steroids, acute illness, H Pylori, ZES, Crohn’s, viral, ischemia; DDx: PUD, celiac disease, pancreatitis, functional, biliary disease, gastric cancer
The patient's HPI is notable for ***. Exam showed ***. Labwork and data were notable for ***. Taken together, the patient's presentation is most concerning for ***, with a differential including ***.
Plan:
Workup
-- f/u H Pylori stool antigen
-- EGD if alarm features (dysphagia, weight loss, vomiting, c/f GI bleed)or >60 years olf got biopsies and H Pylori testing
Treatment
-- Meds: PPI *** BID for 4 weeks for duodenal ulcer, 8 weeks for gastric ulcer; continue omeprazole 20mg daily if large ulcer, recurrent, age >50, unclear etiology; add sucralfate if duodenal ulcer
-- Avoid NSAIDs, and steroids; limit alcohol, smoking, and caffeine
-- H Pylori Tx: *** quadruple therapy (PPI BID, bismuth 300mg daily tetracycline 500mg daily, metronidazole 500mg daily) for 14 days; triple therapy (PPI BID, clarithromycin 500mg BID, amoxicillin 1g BID) for 14 days
-- Confirmation of Eradication: *** (stool Ag, urea breath test, or EGD >4 weeks after completion of treatment pause PPI for 2 weeks before these tests)
-- Repeat EGD 8-12 weeks if recurrent sxs, bleeding, initial ulcer >2cm or c/f malignancy
-- Consider fasting serum gastrin followed by a secretin stimulation test if c/f ZES
-- Consider surgical consult if does not heal after 12-24 weeks
PDF coming soon!
If You Remember Nothing Else
Peptic ulcer disease is the presence of ulcers in the stomach or duodenum. It is most commonly caused by NSAIDs or H Pylori. Pursue an EGD is there are red flags (dysphagia, weight loss, vomiting, c/f GI bleed) and test for H Pylori via stool antigen testing and biopsy. Quadruple therapy is (PPI BID, bismuth 300mg daily, tetracycline 500mg daily, metronidazole 500mg daily) for 14 daysTriple therapy (PPI BID, clarithromycin 500mg BID, amoxicillin 1g BID) for 14 days.
Clinical Pearls
- Peptic ulcer disease is the presence of one or more ulcerative lesions in the stomach or duodenum
- 90% of PUD is caused by H pylori or NSAIDs
- NSAIDs cause ulcers because they block COX-1 production of prostaglandins that would make mucus and bicarbonate which protect against acid
- H Pylori infection usually starts in the antrum and moves to the duodenum and rest of the stomach
- H Pylori secretes urease which alkalinizes the acidic environment allowing them to survive in the gastric lumen
- Pain with eating more consistent with gastric ulcer; 2-5 hours after eating is mre consistent with duodenal ulcer
- Need to be on the lookout for GI bleeding, perforation, and penetration - happens when an ulcer goes deep; inflammation and edema can also cause gastric outlet obstruction
- Refractory ulcers (5-10%) are those that do not heal after 8-12 weeks of adequate treatment
- If you see ulcers in the distal duodenum or jejunum, think ZES
- ZES is due to gastrinoma which secretes gastrin leading parietal cells to release excess hydrochloric acid
- With ulceration, commonly affected arteries include the left gastric artery and gastroduodenal artery
- Curling Ulcer from severe burn - decreased volume leads to hypoxia of stomach tissue
- Cushing Ulcer from brain injury - increased vagal stimulation leads to increased stomach acid production
Trials and Literature
- Meta-Analysis of PPI for acute PUD bleeding prevents rebleeding (NNT 15), but doesn’t prevent death, avoid surgery, or repeat endoscopy
Other Resources
- Clinical Problem Solvers - H Pylori Illness Script
