Peptic Ulcer Disease
Lesions > 5mm: ulcers; Lesions < 5mm: erosions. Most common in gastric antrum and duodenal bulb. Duodenal ulcers > gastric ulcers. Gastric ulcers caused by NSAIDs or H.pylori 90% of the time. Also consider Crohns or Zollinger-Ellison as well.
H.pylori: GN bacilli, associated with lower socioeconomic status. Secretes urease enzyme that produces ammonia to protect bacteria. Test IgG ab ELISA for H.pylori – antibodies can remain for up to 1 yr after tx. Urease assay tests for enzyme – urease breath tests – checks for active infection and check for cure rate. False negative rate with current use of PPI/abx/bismuth. Need to hold for 1-2 weeks.
NSAIDs: endogenous prostanglandin synthesis. Enteric coated doesn’t matter. Risk factors: steroid use, anticoagulants, older age. NSAID-gastric ulcers more likely to cause hemorrhage/perforation. Usually painless, not necessarily dyspepsia. Even if you d/c NSAIDs, ulcers can be present up to 1 year later.
Zollinger-Ellison: 0.1% of peptic ulcers, gastrin-producing endocrine tumor of pancreas/duodenum. Associated with multiple ulcers and diarrhea. Elevated gastrin level. Dx: secretin stimulation test or elevated fasting gastric acid output.
Gastric ulcer pain 5-15min after oral intake, relieved with fasting. Duodenal ulcers relieved temporarily by eating, returns 1-2 hours afterward – also pain can occur at night.
Endoscope: Used primarily in significant dyspepsia, acute GI bleeding, fecal occult blood, abdominal pain of unclear etiology.
H2 blockers: inhibit basal and food-induced acid secretion, renal dosing required. Most effective when given between dinner and bedtime.
PPI: require acid for activation so effective when taken before or with meal and in absence of other antisecretory drugs.
Misoprostol: prostanglin analong that inhibits acid secretion. Can cause diarrhea/spontaneous abortion.
Sucralfate: mucosal protectant.
H.pylori treatment: Triple therapy: clarithromycin 500mg BID, amoxicillin 1g BID, PPI BID for 10-14 days. 4 therapy: Bismuth, tetracycline, flagyl, and PPI for PCN allergy patients.