Gastroenterology Book

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Peptic Ulcer DiseaseAka: PUD, Gastric Ulcer, Duodenal Ulcer

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  1. See Also
    1. Dyspepsia
  2. Epidemiology
    1. Incidence: 500,000 cases per year in U.S.
  3. Etiologies
    1. Nonsteroidal Antiinflammatory Drugs (NSAIDs)
      1. Peptic ulcers occur in 5-20% of longterm NSAID use
    2. Helicobacter Pylori
      1. Duodenal Ulcer: 90-100% Prevalence
      2. Gastric Ulcer: 70-90% Prevalence
    3. Acid Induced Ulcers
      1. Idiopathic
      2. Zollinger-Ellison Syndrome
    4. Chronic Disease
      1. Stress Ulcers in chronic debilitated conditions
      2. Chronic Obstructive Pulmonary Disease
      3. Cystic Fibrosis
      4. Alpha-1-Antitrypsin Deficiency
      5. Systemic Mastocytosis
      6. Basophilic Leukemia
      7. Chronic Renal Failure
      8. Cirrhosis
  4. Risk Factors
    1. See Gastric Irritants
  5. Symptoms
    1. Duodenal Ulcer
      1. Mid-Epigastric Pain, deep recurring ache
      2. Relieved with food or antacids
      3. Aggravated by general irritants (below)
      4. Nocturnal pain is present
    2. Gastric Ulcer
      1. Mid-Epigastric Pain
      2. Relieved by antacids
      3. Aggravated by food and general irritants (below)
      4. Constitutional symptoms
        1. Anorexia
        2. Weight loss
        3. Nausea or Vomiting
  6. Red Flags
    1. See Dyspepsia Red Flags
  7. Presentations: Special cohorts
    1. Children (rare): Presents with poorly localized Abdominal Pain
    2. Elderly
      1. Presents asymptomatically or non-specifically (e.g. confusion, abdominal distention)
      2. High risk of perforation and mortality
    3. Stress Ulcers
      1. Presents in seriously ill hospitalized patients (Mechanical Ventilation, burn injury)
    4. Pregnancy
      1. See Dyspepsia in Pregnancy
  8. Differential Diagnosis
    1. See Dyspepsia Causes
    2. See Medication Causes of Dyspepsia
    3. Cholecystitis
    4. Pancreatitis
    5. Appendicitis
    6. Gastric Cancer
    7. Ischemic bowel disease in the elderly
    8. Inflammatory Bowel Disease
  9. Diagnostics
    1. See Dyspepsia for evaluation protocol
    2. No additional investigation necessary if
      1. Symptoms consistent with Duodenal Ulcer and
      2. Medication leads to healing within 6 weeks
    3. Upper Endoscopy Indications
      1. Assess and reassess gastric ulcers
      2. Evaluate for Gastric Carcinoma in high risk groups
        1. See Dyspepsia Red Flags
    4. Upper GI with Follow Through
      1. May be sufficient for duodenal ulcers
    5. Helicobacter Pylori testing if ulcer not NSAID related
      1. See Helicobacter pylori Noninvasive Testing
  10. Management: General Measures
    1. Avoid Gastric Irritants
    2. Avoid bland diets (not effective)
      1. May stimulate greater acid production
  11. Management: Cause specific
    1. NSAID associated peptic ulcer
      1. H2 Antagonist or Proton Pump Inhibitor
      2. Consider Misoprostol
    2. Non-NSAID Associated Peptic Ulcer disease
      1. Helicobacter Pylori Treatment
      2. H2 Antagonist or Proton Pump Inhibitor
  12. Management: Refractory Peptic Ulcer
    1. Causes
      1. Persistent NSAID use
      2. Resistant Helicobacter Pylori infection
      3. Gastric Cancer
      4. Zollinger-Ellison Syndrome
    2. Measures
      1. Continue Proton Pump Inhibitors
      2. Consider surgical intervention in severe cases or those at high risk of complications
        1. Duodenal Ulcer: Vagotomy or Partial Gastrectomy
        2. Gastric Ulcer: Partial Gastrectomy
  13. Prognosis
    1. Proton Pump Inhibitors have higher efficacy than H2 Antagonists
    2. On Proton Pump Inhibitor
      1. Duodenal ulcers heal in 95% of cases within 4 week
      2. Gastric ulcers heal in 80-90% of cases within 8 weeks
    3. Recurrence risk (duodenal ulcers)
      1. Non-smoker recurrence in 1 year: 60%
      2. Smoker recurrence in 1 year: >75%
  14. Complications: 25% of cases (especially in Elderly taking NSAIDs)
    1. Gastrointestinal Hemorrhage (15-20% of cases)
      1. See Upper Gastrointestinal Bleeding
    2. Gastrointestinal Perforation
    3. Gastric Outlet Obstruction
  15. References
    1. Soll in Goldman (2000) Cecil Medicine, p. 671-84
    2. Behrman (2005) Arch Surg 140:201
    3. Ramakrishnan (2007) Am Fam Physician 76(7):1005
    4. Smoot (2001) Prim Care 28(3):487

Duodenal Ulcer (C0013295)

Definition (MSH)A PEPTIC ULCER located in the DUODENUM.
Definition (CSP)peptic ulcer located in the duodenum, the shortest and widest portion of the small intestine adjacent to the pylorus of the stomach.
ConceptsDisease or Syndrome (T047)
ICD9532
BasqueDUODENO ULTZERA
DanishUlcus duodeni
DutchUlcus duodeni
EnglishCommon duodenal ulcer, Duodenal Ulcer, DUODENAL ULCER DISEASE, DUODENAL ULCERATION, Duodenal Ulcers, Peptic ulcer of duodenum, ULCER DUODENAL, Unspecified duodenal ulcer
FinnishPOHJUKAISSUOLEN HAAVA
FrenchUlcere duodenal, Ulcere duodenale
GermanUlcus duodeni
Hebrewkiv hatrisarion
Hungarianulcus duodeni
ItalianUlcera duodenale
NorwegianSAR PA TOLVFINGERTARMEN
PortugueseUlcera duodenal
Spanishúlcera de duodeno, úlcera duodenal, úlcera duodenal común, úlcera duodenal no especificada, úlcera péptica del duodeno, enfermedad ulcerosa del duodeno, ulcera de duodeno, ulcera duodenal, ulcera duodenal comun, ulcera duodenal no especificada, ulcera peptica del duodeno
SwedishDUODENALSAR
CreditsDerived from the NIH UMLS (Unified Medical Language System)


Peptic Ulcer (C0030920)

Definition (MSH)Ulcer that occurs in the regions of the GASTROINTESTINAL TRACT which come into contact with GASTRIC JUICE containing PEPSIN and GASTRIC ACID. It occurs when there are defects in the MUCOSA barrier. The common forms of peptic ulcers are associated with HELICOBACTER PYLORI and the consumption of nonsteroidal anti-inflammatory drugs (NSAIDS).
Definition (CSP)local defect produced by the sloughing of inflammatory necrotic tissue that occurs in the regions of the gastrointestinal tract which come into contact with gastric juice; occurs when there are defects in the mucosa barrier; common forms of peptic ulcers are associated with Helicobacter pylori and the consumption of nonsteroidal antiinflammatory drugs.
ConceptsDisease or Syndrome (T047)
ICD9533
Englishgastroduodenal ulcer, Gastroduodenal Ulcers, PEPTIC ULCER, Peptic ulcer disease, PEPTIC ULCER SYNDROME, Peptic ulcer; site unspecified, Peptic ulceration, Peptic Ulcers, SYNDROME PEPTIC ULCER, ULCER GASTRODUODENAL, ULCER PEPTIC, ULCER SYNDROME PEPTIC, Unspecified peptic ulcer
Spanishúlcera gastroduodenal, úlcera péptica, úlcera péptica no especificada, enfermedad pélvica ulcerosa, enfermedad pelvica ulcerosa, ulcera gastroduodenal, ulcera peptica, ulcera peptica no especificada
CreditsDerived from the NIH UMLS (Unified Medical Language System)


Gastric ulcer (C0038358)

Definition (MSH)Ulceration of the GASTRIC MUCOSA due to contact with GASTRIC JUICE. It is often associated with HELICOBACTER PYLORI infection or consumption of nonsteroidal anti-inflammatory drugs (NSAIDS).
ConceptsDisease or Syndrome (T047) , Anatomical Abnormality (T190)
ICD9531
EnglishGASTRIC ULCER, GASTRIC ULCER DISEASE, Gastric ulceration, Gastric Ulcers, STOMACH ULCER, Stomach Ulcers, ULCER GASTRIC, ULCER STOMACH, ULCUS VENTRICULI, Unspecified gastric ulcer
FrenchUlcere gastrique
ItalianUlcera gastrica
Spanishúlcera de estómago, úlcera gástrica, úlcera gástrica no especificada, ulcera de estomago, ulcera gastrica, ulcera gastrica no especificada
CreditsDerived from the NIH UMLS (Unified Medical Language System)



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