peptic%20ulcer%20disease
PEPTIC ULCER DISEASE
Peptic ulcer disease is the presence of ulceration in the stomach and proximal duodenum commonly and in the lower esophagus, distal duodenum or jejunum infrequently. It is characterized by mucosal damage secondary to pepsin and gastric acid secretion.
It is the principal cause of upper gastrointestinal hemorrhage.
Appropriate therapy depends on the cause of peptic ulcer disease.

Diagnosis

  • Usually based on clinical features and specific testing; however, signs and symptoms are nonspecific

Evaluation

Esophagogastroduodenoscopy (EGD)
  • Identifies gastric and duodenal ulcers, and cancers with 90% sensitivity and specificity
    • Nonsteroidal anti-inflammatory drug (NSAID)-associated lesions typically present with shallow, flat, antral ulcer with associated lesions
  • Recommended in patients with evidence of bleeding, weight loss, chronic peptic ulcer disease (PUD), persistent vomiting or any alarm features that may suggest significant structural disease or malignancy, in patients whose symptoms do not respond to pharmacological therapy, and in >50-year old patients with new-onset dyspepsia
  • Main role in uncomplicated PUD is to confirm the diagnosis and to rule out cancer
  • May be used for surveillance of ulcers
    • Should be considered in patients with duodenal ulcers who have persistent symptoms despite an appropriate therapy
      • May rule out refractory peptic ulcers and ulcers with nonpeptic origin
      • Has low yield if patients’ symptoms resolved after course of acid suppression with eradication treatment for H pylori and discontinuation of NSAIDs
    • May identify gastric cancer early in patients with gastric ulcer, hence improving survival
      • Should be performed depending on patients’ risk for gastric ulcer
      • Should be considered in patients with gastric ulcer without clear etiology and in those who did not undergo biopsy during index EGD
    •  Should be performed in patients with refractory PUD until the ulcer has healed or the etiology has been identified
  • Allows biopsy of gastric lesion
    • Indicated in gastric ulcer with features of cancer (ie associated mass lesion, elevated irregular ulcer borders, and abnormal adjacent mucosal folds)
    • At first, some malignant ulcers may appear endoscopically benign
      • 2-5% of malignant ulcers may have false-negative biopsy results
      • Ulcers that are not healed after 8-12 weeks of medical therapy should have a repeat biopsy
      • There is a 3- to 6-fold increased risk for gastric cancer to develop from H pylori-associated ulcer
    • Routine cytologic brushings may add to sensitivity but are not advised as alternative or adjunct to endoscopic biopsy
  • May also be used in diagnosing, prognosticating, and managing complications of PUD
    • In bleeding PUD, EGD done within 24 hours of admission has been shown to reduce the need for blood transfusion, shorten intensive care unit (ICU) and hospital stays, decrease need for surgery, and lower mortality rate
      • Patients with features of high risk of rebleeding on endoscopy (eg presence of adherent clots, visible vessels, active arterial bleeding) should undergo endoscopic therapy (ie clips, bipolar electrocoagulation, heater probe, sclerosant) to attain hemostasis and to lower the risk of rebleeding
      • Endoscopic hemostasis using epinephrine should be followed by another modality (eg fibrin glue, thrombin, alcohol)
      • Repeat endoscopic therapy is advised prior to considering surgical or radiological intervention in patients who rebleed after initial endoscopic therapy
    • Allows identification of ulcer penetration to adjacent organs like liver and spleen through biopsy obtained via endoscopy
    • Important in confirming the presence and distinguishing benign from malignant obstruction
      • Endoscopic balloon dilation has been used to manage benign gastric outlet obstruction causing good to excellent short-term relief of symptoms in 67-83% of patients
  • Contraindicated in patients with acute perforated peptic ulcer
    • In some studies, role has been limited in identifying perforation site and in guiding subsequent laparoscopic intercorporeal suture repair with omental patch
  • Histological exam, culture, or rapid urease testing for H pylori may also be done endoscopically

Radiologic Upper Gastrointestinal Series

  • May be an option when EGD is not available
  • Not effective in identifying ulcers of <0.5 cm in size and does not allow biopsy

Physical Examination

  • Typically indistinct especially in patients with uncomplicated peptic ulcer disease (PUD)
    • Most patients may only have mild epigastric tenderness
  • Acute abdomen may be present in patients with perforation
  • Succussion splash may be elicited in patients with gastric outlet obstruction
  • Anemia may be observed in patients with hemorrhage

Laboratory Tests

  • With minimal role in evaluating patients with uncomplicated peptic ulcer disease (PUD)
  • Fasting serum gastrin level may be done in patients with duodenal ulcer in whom presence of other diagnosis (eg Zollinger-Ellison syndrome) is suspected
  • H pylori testing is important for diagnosing and managing concomitant infection which may include rapid urease test, serologic enzyme-linked immunosorbent assay (ELISA), urea breath test or stool antigen test

Complications

  • Hemorrhage - internal bleeding can be either a slow or severe blood loss
  • Perforation - acute abdomen presentation
  • Infection - peritonitis may develop following perforation into the abdominal cavity
  • Gastric outlet obstruction - caused by ulcer scarring, inflammation, or spasm
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