II. Epidemiology
- Incidence: 500,000 cases per year in U.S.
III. Etiologies
- Nonsteroidal Antiinflammatory Drugs (NSAIDs)
- Peptic ulcers occur in 5-20% of longterm NSAID use
-
Helicobacter Pylori
- Duodenal Ulcer: 90-100% Prevalence
- Gastric Ulcer: 70-90% Prevalence
- Acid Induced Ulcers
- Idiopathic
- Zollinger-Ellison Syndrome
- Chronic Disease
IV. Risk Factors
- See Gastric Irritants
V. Symptoms
- Duodenal Ulcer
- Mid-Epigastric Pain, deep recurring ache
- Relieved with food or Antacids
- Aggravated by general irritants (below)
- Nocturnal pain is present
- Gastric Ulcer
- Mid-Epigastric Pain
- Relieved by Antacids
- Aggravated by food and general irritants (below)
- Constitutional symptoms
VI. Red Flags
VII. Presentations: Special cohorts
- Children (rare): Presents with poorly localized Abdominal Pain
- Elderly
- Presents asymptomatically or non-specifically (e.g. confusion, Abdominal Distention)
- High risk of perforation and mortality
-
Stress Ulcers
- Presents in seriously ill hospitalized patients (Mechanical Ventilation, Burn Injury)
- Pregnancy
VIII. Differential Diagnosis
- See Dyspepsia Causes
- See Medication Causes of Dyspepsia
- Most common misdiagnoses for Peptic Ulcer Disease
- Less common misdiagnoses for Peptic Ulcer Disease
- Uncommon misdiagnoses for Peptic Ulcer Disease
- Abdominal Aortic Aneurysm
- Acute Coronary Syndrome
- Barrett Esophagus
- Gastric Cancer
- Ischemic bowel disease in the elderly
- Viral Hepatitis
- Zollinger-Ellison Syndrome
IX. Diagnostics
- See Dyspepsia for evaluation protocol
- No additional investigation necessary if
- Symptoms consistent with Duodenal Ulcer and
- Medication leads to healing within 6 weeks
- Upper Endoscopy Indications
- Assess and reassess Gastric Ulcers
- Evaluate for Gastric Carcinoma in high risk groups
- Upper GI with Follow Through
- May be sufficient for Duodenal Ulcers
- Helicobacter Pylori testing if ulcer not NSAID related
X. Management: General Measures
- Avoid Gastric Irritants
- Avoid bland diets (not effective)
- May stimulate greater acid production
- Avoid Glycopyrolate Dartisla ODT
- Glycopyrolate was originally used in the 1960s for peptic ulcers to reduce gastric secretions
- However, since that time, much more effective medications are available (e.g. H2 Blockers, Proton Pump Inhibitors)
- Yet, in 2022 Dartisla ODT was released in 2022, at $500/90 tablets, a 10 fold markup over generic glycopyrolate
- Avoid glycopyrolate (including Dartisla ODT) in Peptic Ulcer Disease (we have much better. less expensive treatments)
- (2022) Presc Lett 29(4): 24
XI. Management: Cause specific
-
NSAID associated peptic ulcer
- H2 Antagonist or Proton Pump Inhibitor
- Consider Misoprostol
-
Non-NSAID Associated Peptic Ulcer disease
- Helicobacter Pylori test and treatment
- H2 Antagonist or Proton Pump Inhibitor
XII. Management: Refractory Peptic Ulcer
- Causes
- Persistent NSAID use
- Resistant Helicobacter Pylori infection
- Gastric Cancer
- Zollinger-Ellison Syndrome
- Measures
- Continue Proton Pump Inhibitors
- Consider surgical intervention in severe cases or those at high risk of complications
- Duodenal Ulcer: Vagotomy or Partial Gastrectomy
- Gastric Ulcer: Partial Gastrectomy
XIII. Prevention
- Avoid NSAIDs
- See NSAID Gastrointestinal Adverse Effects for risks (and prophylaxis options if NSAIDS are needed)
XIV. Prognosis
- Proton Pump Inhibitors have higher efficacy than H2 Antagonists
- On Proton Pump Inhibitor
- Duodenal Ulcers heal in 95% of cases within 4 week
- Gastric Ulcers heal in 80-90% of cases within 8 weeks
- Recurrence risk (Duodenal Ulcers)
- Non-smoker recurrence in 1 year: 60%
- Smoker recurrence in 1 year: >75%
XV. Complications
- Complications occur in 25% of cases (especially in Elderly taking NSAIDs)
- Gastrointestinal Hemorrhage (15-20% of cases)
- Gastrointestinal Perforation
- Incidence: 1 per 10,000 per year for non-NSAID related peptic ulcer perforation
- Presents with severe Abdominal Pain, Acute Abdomen, with regional inflammation (Pancreatitis, hepatitis)
- Lowest mortality (6-14%) is associated with the earliest management in younger patients without comorbidity
- Gastric Outlet Obstruction (rare)
- Duodenum narrows with recurrent or persistent ulceration and secondary inflammation and scarring
- Presents with Retching and hematemsis
- Evaluate differential diagnosis including cancer
XVI. References
- Soll in Goldman (2000) Cecil Medicine, p. 671-84
- Behrman (2005) Arch Surg 140:201-8 [PubMed]
- Fashner (2015) Am Fam Physician 91(4): 236-42 [PubMed]
- Ramakrishnan (2007) Am Fam Physician 76(7):1005-12 [PubMed]
- Smoot (2001) Prim Care 28(3):487-503 [PubMed]