PEPTIC ULCER DISEASE.

Ulceration in the duodenal or gastric mucosa occurring when normal defense factors are impaired allowing erosion into the mucosal lining.

ETIOLOGY/ PATHOGENESIS

  • Gastric
  • Duodenal: more common
  • Occurs as a break in the gastric or duodenal mucosa when normal defensive factors are impaired or overwhelmed by acid and pepsin
  • More common in smokers
  • Causes: Chronic H. pylori (most common), NSAIDS, acid hypersecretion, Severe physiologic stress
  • Complications include hemorrhage and perforations
  • Stomach Malignancy associated with H Pylori, no increased risk of cancer
  • Associated with ulcers of other causes.

PERTINENT HISTORICAL FINDINGS/ CLINICAL SYMPTOMS

  • Dull gnawing pain
  • Periodic pain radiating to back or left upper quadrant
  • NSIADS ulcers are often painless
  • Pain may be exacerbated or relieved by food
  • Nausea, vomiting, hematemesis, and melana
  • Duodenal: Pain improves with food, pain occurs hours after meals and at night
  • Gastric: pain worsens shortly after meals = associated weight loss

PERTINENT PHYSICAL EXAM FINDINGS

  • Usually unrevealing

DIFFERENTIAL DIAGNOSIS

  • Dyspepsia
  • Gastritis
  • Neoplasms
  • Ischemic heart disease

DIAGNOSTIC EVALUATIONS

  • Upper endoscopy (choice testing): include biopsy for HP
  • Also, urea breath testing for HP
  • Stool Antigen test for HP (more accurate than serology)
  • Serology for HP

MEDICAL MANAGEMENT

  • Remove or discontinue offending agent (smoking, alcohol, NSAID)
  • H2 blockers
  • PPIs are most effective
  • For HP, bismuth with metronidazole and any two of the following: tetracycline, Clarithromycin,  or amoxicillin

SURGICAL MANAGEMENT (when applicable)

  • Surgical management for perforations
  • Endoscopy for hemorrhages to locate and stop bleeding

EMERGENCY MANAGEMENT (when applicable)

  • Hemodynamic treatment for hemorrhages and perforations (see surgical treatment)

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Dr. Zachary Lahlou

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