Peptic ulcer disease: Clinical sciences

Peptic Ulcer Disease, or PUD for short, is a condition characterized by ulcers in areas exposed to excess gastric acid and peptic juices. So, peptic ulcers can be located in the stomach, typically on the lesser curvature, which are referred to as gastric ulcers; or in the duodenum, usually in the duodenal bulb, which are referred to as duodenal ulcers.

There are two main causes of PUD - Helicobacter Pylori, or H. Pylori infections, and Non-Steroidal Anti Inflammatory Drugs, or NSAIDs. PUD can result in complications, such as bleeding, perforation, and malignancy.

Now, when assessing a patient with suspected PUD, the first thing you should do is an ABCDE assessment, to determine if your patient is unstable or stable. In unstable individuals, history might reveal alarm symptoms such as melena, severe hematochezia, or large-volume hematemesis, indicating a GI bleed. They may also report persistent severe epigastric pain. Additionally, physical exam findings can include orthostatic hypotension, tachycardia, pallor, and epigastric tenderness to palpation, suggesting a possible active GI bleed or even perforation.

A high yield fact to remember is if your patient with suspected PUD also reports unintentional weight loss, be on the lookout for malignancies!

Now for unstable patients, the goal is to immediately stabilize them. You might need to place two large bore IVs, initiate cardiac monitoring, start IV fluid resuscitation and transfuse blood products.

After you’ve stabilized the patient, you should determine the cause of the instability. The peptic ulcer itself can be causing a severe GI bleed or worse yet, it may have perforated. But, to confirm any of these diagnoses, first you need to order a diagnostic Esophagogastroduodenoscopy, or EGD with biopsies. Order iron studies and monitor the patient with serial CBCs. Consider a surgical consultation if there’s a perforation.

Alright, moving on to treatment. If a bleeding ulcer is suspected, you should start antisecretory therapy via IV Proton Pump Inhibitor, or PPI.

The bleeding should be stopped during endoscopy. If you are unable to stop the bleeding endoscopically, you should consult the surgical team. On the flip side, if you suspect an underlying malignancy, you might obtain an oncology consultation.

Once you stop the bleeding, the next step is to give high-dose PPI for 3 days before assessing the need for ongoing acid suppression with long-term antisecretory therapy.

Indications for continued acid suppression include a persistent ulcer on repeat EGD; a giant ulcer greater than 2 cm in a patient over the age of 50; and a history of recurrent ulcers, or more than 2 ulcers in a year. Additionally, you should continue acid suppression if a patient is on long-term NSAID therapy.

So, if you find any of these, initiate long-term antisecretory therapy with oral PPIs and advise lifestyle changes like avoiding alcohol and smoking cessation.

On the other hand, if none of these criteria areis met, there’s no need for further treatment, unless symptoms recur.

Ok, now that we’re done with the treatment for unstable patients, let’s take a look at stable patients. In history, these patients typically report epigastric abdominal pain, bloating, and nausea. They may also have a history of NSAID and corticosteroid use, H.Pylori infection, or previous ulcers. On physical exam, you will usually encounter tenderness to palpation in the epigastrium.

Now, if you suspect PUD based on the patient’s history and physical exam findings, move on to H. Pylori testing. The method of testing depends on the patient’s age. If the patient is less than 60 years old, test for H.pylori with a urea breath test or stool antigen. On the other hand, if the patient is 60 years or older, proceed with an EGD and biopsy. This is a high yield fact, because the risk for malignancy increases as patients age!