PUD
Peptic Ulcer Disease
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Peptic Ulcer Disease
, PUD, Gastric Ulcer, Duodenal Ulcer
See Also
Dyspepsia
Epidemiology
Incidence
: 500,000 cases per year in U.S.
Etiologies
Nonsteroidal Antiinflammatory Drugs (
NSAID
s)
Peptic ulcers occur in 5-20% of longterm
NSAID
use
Helicobacter Pylori
Duodenal Ulcer: 90-100%
Prevalence
Gastric Ulcer: 70-90%
Prevalence
Acid Induced Ulcers
Idiopathic
Zollinger-Ellison Syndrome
Chronic Disease
Stress Ulcer
s in chronic debilitated conditions
Chronic Obstructive Pulmonary Disease
Cystic Fibrosis
Alpha-1-Antitrypsin Deficiency
Systemic Mastocytosis
Basophil
ic
Leukemia
Chronic Renal Failure
Cirrhosis
Risk Factors
See
Gastric Irritant
s
Symptoms
Duodenal Ulcer
Mid-
Epigastric Pain
, deep recurring ache
Relieved with food or
Antacid
s
Aggravated by general irritants (below)
Nocturnal pain is present
Gastric Ulcer
Mid-
Epigastric Pain
Relieved by
Antacid
s
Aggravated by food and general irritants (below)
Constitutional symptoms
Anorexia
Weight loss
Nausea
or
Vomiting
Red Flags
See
Dyspepsia Red Flags
Presentations
Special cohorts
Children (rare): Presents with poorly localized
Abdominal Pain
Elderly
Presents asymptomatically or non-specifically (e.g. confusion,
Abdominal Distention
)
High risk of perforation and mortality
Stress Ulcer
s
Presents in seriously ill hospitalized patients (
Mechanical Ventilation
,
Burn Injury
)
Pregnancy
See
Dyspepsia in Pregnancy
Differential Diagnosis
See
Dyspepsia Causes
See
Medication Causes of Dyspepsia
Most common misdiagnoses for Peptic Ulcer Disease
Functional Dyspepsia
Esophagitis
Gastroesophageal Reflux
Gastritis
Gastroenteritis
Less common misdiagnoses for Peptic Ulcer Disease
Biliary tract disease (
Cholecystitis
,
Cholelithiasis
,
Ascending Cholangitis
)
Celiac Sprue
(
Gluten Sensitive Enteropathy
)
Inflammatory Bowel Disease
Irritable Bowel Syndrome
Pancreatitis
Appendicitis
Uncommon misdiagnoses for Peptic Ulcer Disease
Abdominal Aortic Aneurysm
Acute Coronary Syndrome
Barrett Esophagus
Gastric Cancer
Ischemic bowel disease in the elderly
Viral Hepatitis
Zollinger-Ellison Syndrome
Diagnostics
See
Dyspepsia
for evaluation protocol
No additional investigation necessary if
Symptoms consistent with Duodenal Ulcer and
Medication leads to healing within 6 weeks
Upper Endoscopy Indications
Assess and reassess Gastric Ulcers
Evaluate for
Gastric Carcinoma
in high risk groups
See
Dyspepsia Red Flags
Upper GI with Follow Through
May be sufficient for Duodenal Ulcers
Helicobacter Pylori
testing if ulcer not
NSAID
related
See
Helicobacter pylori Noninvasive Testing
Management
Gene
ral Measures
Avoid
Gastric Irritant
s
Avoid
Alcohol
Avoid
Tobacco
Avoid
Caffeine
Avoid bland diets (not effective)
May stimulate greater acid production
Avoid Glycopyrolate Dartisla ODT
Glycopyrolate was originally used in the 1960s for peptic ulcers to reduce gastric secretions
However, since that time, much more effective medications are available (e.g.
H2 Blocker
s,
Proton Pump Inhibitor
s)
Yet, in 2022 Dartisla ODT was released in 2022, at $500/90 tablets, a 10 fold markup over generic glycopyrolate
Avoid glycopyrolate (including Dartisla ODT) in Peptic Ulcer Disease (we have much better. less expensive treatments)
(2022) Presc Lett 29(4): 24
Management
Cause specific
NSAID
associated peptic ulcer
H2 Antagonist
or
Proton Pump Inhibitor
Consider
Misoprostol
Non-NSAID Associated Peptic Ulcer
disease
Helicobacter Pylori
test and treatment
H2 Antagonist
or
Proton Pump Inhibitor
Management
Refractory Peptic Ulcer
Causes
Persistent
NSAID
use
Resistant
Helicobacter Pylori
infection
Gastric Cancer
Zollinger-Ellison Syndrome
Measures
Continue
Proton Pump Inhibitor
s
Consider surgical intervention in severe cases or those at high risk of complications
Duodenal Ulcer: Vagotomy or Partial Gastrectomy
Gastric Ulcer: Partial Gastrectomy
Prevention
Avoid
NSAID
s
See
NSAID Gastrointestinal Adverse Effects
for risks (and prophylaxis options if
NSAID
S are needed)
Prognosis
Proton Pump Inhibitor
s have higher efficacy than
H2 Antagonist
s
On
Proton Pump Inhibitor
Duodenal Ulcers heal in 95% of cases within 4 week
Gastric Ulcers heal in 80-90% of cases within 8 weeks
Recurrence risk (Duodenal Ulcers)
Non-smoker recurrence in 1 year: 60%
Smoker recurrence in 1 year: >75%
Complications
Complications occur in 25% of cases (especially in Elderly taking
NSAID
s)
Gastrointestinal
Hemorrhage
(15-20% of cases)
See
Upper Gastrointestinal Bleeding
Gastrointestinal Perforation
Incidence
: 1 per 10,000 per year for non-
NSAID
related peptic ulcer perforation
Presents with severe
Abdominal Pain
,
Acute Abdomen
, with regional inflammation (
Pancreatitis
, hepatitis)
Lowest mortality (6-14%) is associated with the earliest management in younger patients without comorbidity
Gastric Outlet Obstruction (rare)
Duodenum narrows with recurrent or persistent ulceration and secondary inflammation and scarring
Presents with
Retching
and hematemsis
Evaluate differential diagnosis including cancer
References
Soll in Goldman (2000) Cecil Medicine, p. 671-84
Behrman (2005) Arch Surg 140:201-8 [PubMed]
Fashner (2015) Am Fam Physician 91(4): 236-42 [PubMed]
Ramakrishnan (2007) Am Fam Physician 76(7):1005-12 [PubMed]
Smoot (2001) Prim Care 28(3):487-503 [PubMed]
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