Updated: 9/25/2019

Peptic Ulcer Disease

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Snapshot
  • A 45-year-old male presents to the clinic for black stool for the past day. He reports intermittent epigastric pain that is worse with food intake for the past 4 months. The pain is described as dull, 6/10, nonradiating and improves with antacids. He reports a 5-lb. unintended weight loss but denies diarrhea, constipation, cancer history, or fevers. A physical examination is unremarkable. 
Introduction
  • Clinical definition
    • characterized by erosion and defects in the mucosal lining of the stomach, duodenum, and sometimes the lower esophagus that persist as a function of the acid or peptic activity in gastric juice
      • gastric ulcers describe ulcers occurring at the stomach
      • duodenal ulcers describe ulcers occurring at the duodenum
    • duodenal ulcers
      • abdominal pain is relieved with food intake
      • the majority (90%) of cases are secondary to Helicobacter pylori
    • gastric ulcers
      • abdominal pain is exacerbated with food intake
      • the leading causes are H. pylori followed by nonsteroidal anti-inflammatory drugs (NSAIDs) 
  • Epidemiology
    • demographics
      • ulcer incidence increases with age
      • H. pylori is the predominant cause of peptic ulcer disease (PUD) worldwide
      • increasing prevalence of NSAID-related PUD due to widespread use of aspirin and NSAID
    • risk factors
      • NSAIDs
      • smoking
      • stress
      • age
  • Pathogenesis
    • development of ulcers is secondary to the disruption of normal protective mechanisms of the gastric mucosa (e.g., bicarbonate)
    • H. pylori
      • secretion of urease creates an alkaline environment which allows for the survival of the bacteria
      • inflammatory cytokines inhibit parietal cell acid secretion causing gastric ulcers
      • at the pyloric antrum, somatostatin production is reduced and gastric production is increased, leading to metaplasia of the duodenal cells and causing duodenal ulcers
    • NSAIDs
      • mechanism of action blocks the function of cyclooxygenase-1 (COX-1), which is essential for the production of prostaglandins that stimulates the secretion of mucous that protects the gastric mucosa
      • also inhibits stomach mucosa cell proliferation and mucosal blood flow
    • other causes
      • stress from serious illness
      • gastric ischemia
      • metabolic disturbances
      • vasculitis
      • gastrinoma (Zollinger-Ellison syndrome)
  • Associated conditions
    • Zollinger-Ellison syndrome
      • suspect in patients with refractory duodenal ulcers
    • Behcet disease
    • Crohn disease
Presentation
  • Symptoms 
    • abdominal pain
      • most commonly at the upper quadrants
    • belching
    • vomiting
    • weight loss
    • poor appetite
    • bloating
    • hematemesis
    • melena
  • Physical exam
    • abdominal tenderness
    • peritoneal signs if perforation
Evaluation
  • Diagnostic testing
    • diagnostic approach
      • diagnosis is primarily based on clinical presentation and preemptive treatment, confirmation of the diagnosis is made via endoscopy
    • imaging
      • esophagogastroduodenoscopy (EGD)
        • gold standard of diagnosis
        • indicated in patients who show no symptom improvement following few weeks of treatment
        • allows for direct visual identification and allows for evaluation of the location and severity of the disease 
        • biopsy is important for the differentiation between benign ulcers and malignancy 
      • abdominal and chest radiographs 
        • may be useful in detecting pneumoperitoneum secondary to perforation
        • positive findings include air-fluid levels with bowel dilation or free air
    • studies
      • urease breath test
        • best initial test
        • noninvasive and allows for the detection of H. pylori infection
      • complete blood count
        • often normal
      • serum gastrin 
        • can be used to evaluate Zollinger-Ellison syndrome 
Differential
  • Gastric malignancy 
    • differentiating factors
      • lesions will appear different on endoscopy and will be confirmed via biopsy
  • Chronic pancreatitis 
    • differentiating factors
      • may have characteristic disease history and will present with calcifications on abdominal imaging
Treatment
  • Management depends on disease etiology and severity
  • H. pylori-induced PUD
    • clarithromycin, amoxicillin, and pantoprazole for 7-14 days 
    • clarithromycin, amoxicillin, pantoprazole, and metronidazole for 7-14 days
  • NSAID-induced PUD
    • stop NSAID use
    • introduce proton pump inhibitor (PPI) use
  • Bleeding ulcers
    • resuscitation with IV fluids and/or blood products
    • IV PPI
    • endoscopic therapy with either cautery, endoclip or epinephrine injection
  • Surgery
    • indicated in patients with perforated ulcer and/or hemorrhage 
      • requires IV antibiotics and PPI prior to repair
    • other indications include PUD refractory to medical therapy and Zollinger-Ellison syndrome
Complications 
  • Bleeding
  • Perforation
    • manage with broad spectrum antibitoics, PPI, and emergency surgery 
  • Obstruction
  • Malignancy
 

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Questions (4)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M2.GI.13) A 75-year-old male presents with a 1-month history of severe abdominal and epigastric pain. He states that his pain improves with meals but worsens approximately one hour after eating. He has a history of osteoarthritis, which he treats with NSAIDs; he has increased his dose for the past 3 months due to increased pain. Vital signs are stable and within normal limits. Endoscopy is performed, and the results are shown in Figure A. What is the most common complication of this patient's condition? Review Topic

QID: 106086
FIGURES:
1

Perforation

4%

(1/25)

2

Hemorrhage

80%

(20/25)

3

Obstruction

0%

(0/25)

4

Intractable pain

4%

(1/25)

5

Strictures

8%

(2/25)

M2

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SUBMIT RESPONSE 2

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(M3.GI.72) A 53-year-old man presents to the emergency department with abdominal pain and hematemesis. The patient’s history is significant for osteoarthritis, for which he has been taking ibuprofen for several years. He states he has had epigastric abdominal pain during meals for several months but has never experienced pain like this. His temperature is 99.0°F (37.2°C), blood pressure is 144/94 mmHg, pulse is 110/min, respirations are 15/min, and oxygen saturation is 98% on room air. Physical exam reveals marked abdominal pain with rebound tenderness and involuntary guarding. A chest radiograph is performed as seen in Figure A. The patient is transferred to the operating room. While the patient is preparing for transport, which of the following treatments should be administered? Review Topic

QID: 103013
FIGURES:
1

Octreotide, ceftriaxone, and metronidazole

0%

(0/3)

2

Octreotide, pantoprazole, piperacillin-tazobactam, and vancomycin

67%

(2/3)

3

Pantoprazole, metronidazole, and clindamycin

0%

(0/3)

4

Pantoprazole, piperacillin-tazobactam, and vancomycin

33%

(1/3)

5

Piperacillin-tazobactam and vancomycin

0%

(0/3)

M2

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SUBMIT RESPONSE 4
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