Peptic Ulcer Disease

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