Peptic Ulcer Disease

Aka: Peptic Ulcer Disease, PUD, Gastric Ulcer, Duodenal Ulcer

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II. Epidemiology

  1. Incidence: 500,000 cases per year in U.S.

III. 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

IV. Risk Factors

  1. See Gastric Irritants

V. 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

VI. Red Flags

  1. See Dyspepsia Red Flags

VII. 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

VIII. Differential Diagnosis

  1. See Dyspepsia Causes
  2. See Medication Causes of Dyspepsia
  3. Most common misdiagnoses for Peptic Ulcer Disease
    1. Functional Dyspepsia
    2. Esophagitis
    3. Gastroesophageal Reflux
    4. Gastritis
    5. Gastroenteritis
  4. Less common misdiagnoses for Peptic Ulcer Disease
    1. Biliary tract disease (Cholecystitis, Cholelithiasis, Ascending Cholangitis)
    2. Celiac Sprue (Gluten Sensitive Enteropathy)
    3. Inflammatory Bowel Disease
    4. Irritable Bowel Syndrome
    5. Pancreatitis
    6. Appendicitis
  5. Uncommon misdiagnoses for Peptic Ulcer Disease
    1. Abdominal Aortic Aneurysm
    2. Acute Coronary Syndrome
    3. Barrett Esophagus
    4. Gastric Cancer
    5. Ischemic bowel disease in the elderly
    6. Viral Hepatitis
    7. Zollinger-Ellison Syndrome

IX. 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

X. Management: General Measures

  1. Avoid Gastric Irritants
    1. Avoid Alcohol
    2. Avoid Tobacco
    3. Avoid Caffeine
  2. Avoid bland diets (not effective)
    1. May stimulate greater acid production
  3. Avoid Glycopyrolate Dartisla ODT
    1. Glycopyrolate was originally used in the 1960s for peptic ulcers to reduce gastric secretions
    2. However, since that time, much more effective medications are available (e.g. H2 Blockers, Proton Pump Inhibitors)
    3. Yet, in 2022 Dartisla ODT was released in 2022, at $500/90 tablets, a 10 fold markup over generic glycopyrolate
    4. Avoid glycopyrolate (including Dartisla ODT) in Peptic Ulcer Disease (we have much better. less expensive treatments)
    5. (2022) Presc Lett 29(4): 24

XI. 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 test and treatment
    2. H2 Antagonist or Proton Pump Inhibitor

XII. 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

XIII. Prevention

  1. Avoid NSAIDs
    1. See NSAID Gastrointestinal Adverse Effects for risks (and prophylaxis options if NSAIDS are needed)

XIV. 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%

XV. Complications

  1. Complications occur in 25% of cases (especially in Elderly taking NSAIDs)
  2. Gastrointestinal Hemorrhage (15-20% of cases)
    1. See Upper Gastrointestinal Bleeding
  3. Gastrointestinal Perforation
    1. Incidence: 1 per 10,000 per year for non-NSAID related peptic ulcer perforation
    2. Presents with severe Abdominal Pain, Acute Abdomen, with regional inflammation (Pancreatitis, hepatitis)
    3. Lowest mortality (6-14%) is associated with the earliest management in younger patients without comorbidity
  4. Gastric Outlet Obstruction (rare)
    1. Duodenum narrows with recurrent or persistent ulceration and secondary inflammation and scarring
    2. Presents with Retching and hematemsis
    3. Evaluate differential diagnosis including cancer

XVI. References

  1. Soll in Goldman (2000) Cecil Medicine, p. 671-84
  2. Behrman (2005) Arch Surg 140:201-8 [PubMed]
  3. Fashner (2015) Am Fam Physician 91(4): 236-42 [PubMed]
  4. Ramakrishnan (2007) Am Fam Physician 76(7):1005-12 [PubMed]
  5. Smoot (2001) Prim Care 28(3):487-503 [PubMed]

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