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Source: Berardi RR, Fugit RV. Peptic Ulcer Disease. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy: A Pathophysiologic Approach. 8th ed. http://accesspharmacy.com/content.aspx?aid=7977732. Accessed June 23, 2012.

  • PUD
  • Ulcers

  • A group of ulcerative disorders of the upper gastrointestinal (GI) tract that require acid and pepsin for formation.

  • Ulcers occur in presence of acid and pepsin when various factors disrupt normal mucosal defense and healing mechanisms.
  • Common causes:
    • Helicobacter pylori (HP) infection
    • Nonsteroidal anti-inflammatory drugs (NSAIDs)
    • Critical illness (stress-related mucosal damage)
  • Uncommon causes:
    • Hypersecretion of gastric acid (Zollinger-Ellison syndrome)
    • Viral infections
    • Radiation therapy
    • Cancer chemotherapy
    • Medical illnesses (cirrhosis, chronic kidney disease)

  • Alterations in mucosal defense most important factors in ulcer formation.
  • HP infection causes release of enzymes (urease, lipases, proteases) that cause gastric inflammation and mucosal injury.
  • NSAIDs cause gastric mucosal damage by:
    • Direct irritation of gastric epithelium
    • Systemic inhibition of endogenous mucosal prostaglandin synthesis
  • Cigarette smoking impairs ulcer healing and may be associated with ulcer-related GI complications.

  • 500,000 new cases and 4 million ulcer recurrences per year in United States.
  • Incidence of duodenal ulcers decreasing but incidence of gastric ulcers increasing.
  • Gastric ulcers are slightly more common in men than women.
  • Duodenal ulcers most common between ages 30–55; gastric ulcers most common between ages 55–70.

  • HP infection
  • NSAID use
  • Critical illness
  • Smoking

Signs and Symptoms

  • Epigastric or abdominal pain described as burning, vague discomfort, fullness, or cramping.
  • Nocturnal pain may awaken patients from sleep.
  • Pain from duodenal ulcers often occurs 1–3 hours after meals and usually relieved by food, whereas food may aggravate gastric ulcer pain.
  • Heartburn, belching, and bloating often accompany pain.
  • Nausea, vomiting, and anorexia more common in gastric than duodenal ulcers.
  • Absence of pain does not preclude ulcer diagnosis, especially in elderly who may present with silent ulcer complication.
  • Complications include:
    • Upper GI bleeding
    • Perforation
    • Penetration into adjacent structure
    • Gastric outlet obstruction
  • Bleeding may be occult or present as melena or hematemesis.

Means of Confirmation and Diagnosis

  • Physical examination may reveal epigastric tenderness.

Laboratory Tests

  • Urea breath test (UBT), serologic antibody detection tests, and stool antigen test used to diagnose HP infection.
  • Hematocrit, hemoglobin, and stool guaiac tests used to detect bleeding.

Imaging

  • GI radiography has been largely supplanted by endoscopy.

Diagnostic Procedures

  • Upper GI endoscopy provides more accurate diagnosis than radiography and permits direct visualization of ulcer.

Differential Diagnosis

  • Functional dyspepsia
  • Gastritis from NSAIDs, alcohol, stress, or HP
  • Biliary disease or pancreatitis
  • Gastroesophageal reflux disease (GERD)
  • Indigestion from overeating, high-fat foods, coffee
  • Gastric or pancreatic cancer
  • Angina pectoris

  • Relieve ulcer pain.
  • Eradicate HP if present.
  • Heal ulcer.
  • Prevent ulcer recurrence.
  • Reduce ulcer-related complications.
  • Employ cost-effective therapy.

  • Figure 1: Algorithm for evaluation and management of patient with dyspeptic or ulcer-like symptoms

Figure ...

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