Peptic Ulcer Disease PUD

Epidemiology

• Lifetime prevalence 10%

• Duodenal ulcer (DU) and gastric ulcer (GU) prevalence i over last decade

(l DU > 1 GU). due in part to 1 incidence H. pylori; incidence of hospitalization for complications unA'd (in fact T in elderly; likely 2° to t NSAID use in this group)

Principal etiologies (lorKrt 2002:360933)

30% of population colonized with H. pylori, but only 15% will develop an ulcer

• Gastrinoma (Zollinger-Ellison) & other hypersecretory states (consider if mult, recur.

ulcers)

• Other: smoking, stress ulcers (if CNS process "Cushing's"; if burn "Curlings"). XRT.

chemo. CMV (immunocompromised Pts), bisphosphonates; steroids alone not risk factor, however, may exacerbate NSAID-induced ulceration

Clinical manifestations

• Epigastric abdominal pain, relieved with food (duodenal) or worsened by food (gastric)

• Complications include UGIB. perforation & penetration, gastric outlet obstruction Diagnostic studies

• Tests for H. pylon serology (90% Se. 70-80% Sp. not useful in confirming erad. as can stay ® wks to y) urea breath test (UBT. Se & Sp -90%)

stool antigen (HpSA. 89-98% Se. -90% Sp. useful in confirming eradication) EGD • rapid urease testing (eg. CLOtest, Se & Sp >95%) or bx and histology

• EGD more sensitive (-95%) than UGI series to detect PUD

biopsies should be taken of all GU: DU rarely malignant... routine biopsy not rec. Treatment (nejm 2002:347: ii75)

• H. pylori eradication: clarithromycin 500 mg bid • amoxicillin 1 g bid ♦ PPI bid x

10-14 d is 1" line Rx. but recent i in eradication rates to 70% b/cT clarithro resist, metronidazole 500 mg bid can be substituted for amoxicillin in penicillin-allergic Pts quadruple therapy (MNZ • tetracycline • bismuth subsalicylate • PPI) can be given in cases of H. pylori resistance to clarithromycin or MNZ eradicauon should be documented via UBT or HpSA in Pts w hx GIB or perforated ulcer

• If H. pylori negative, acid suppression with PPI

• Discontinue NSAIDs; if must continue, consider:

adding PPI (nejm 1998.338.719 « 727)

adding misoprostol (A/woh 1995.123 241); however, causes diarrhea A to COX-2 selective inhibitor (i PUD and UGIB but T risk of serious CV events) consider only in Pts w low CV risk not on ASA (as no Gl benefit if concomitant ASA)

• Lifestyle changes: discontinue smoking and ? EtOH; diet irrelevant

• Endoscopy: acutely to control UGIB (also see "Gastrointestinal Bleeding"); to document resolution of GU after Rx (..indicated only if ulcer suspicious for malignancy); if sx do not resolve; or ulcer was large or complicated on previous endoscopy

• Surgery: usually reserved for rare cases refractory to medical management (rule out surreptitious NSAID use) or for complications (see above)

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