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.