Peptic Ulcer Disease
Chronic illness, recurrent ulcers in stomach and duodenum most commonly due to H. Pylori and NSAIDs. 10% people in the western world will have this in their lifetime.
Symptoms:
- Burning, gnawing, achy, “empty, hungry” epigastric pain
- Relieved by ingestion of food (usually), milk, antacids (buffers/dilutes gastric acid)
- Worsens after gastric emptying, classically the pain awakens patients at night
- Chronic ulcers can be asymptomatic or cause painless GI bleeding
- NOT (usually) related to PUD: pain after eating, nausea, belching
- “Alarm features” for suspicion of cancer –> need more emergent endoscopy: >50 yo, weight loss, persistent vomiting, dysphagia/odynophagia, GIB, abdominal mass, lymphadenopathy, Family hx
Physical Exam: For uncomplicated PUD, expect benign physical exam +/- epigastric tenderness (not sensitive or specific). VS should be normal.
Workup: Generally includes CBC to rule out anemia from chronic GIB. Consider LFT, lipase, EKG, trop, upright CXR, RUQ US to rule out other etiologist that may present similarly with epigastric pain if indicated. Gold standard for diagnosis is endoscopy.
Treatment:
- Stop NSAIDs
- Proton pump inhibitors: decrease acid secretion from gastric parietal cells, irreversibly bind with H+K+ATPase (proton pump).
- Example: omeprazole, pantoprazole.
- Heal ulcers faster than any other tx.
- H2 receptor antagonists: Inhibit action of histamine on H2 receptor on gastric parietal cells
- Example: famotidine, ranitidine.
- Dose should be adjusted for patients in renal failure.
- Sucralfate: covers ulcer crater, protects it and allows healing, but doesn’t relieve pain as well
- Antacids: buffer gastric acid. Use for breakthrough pain. (Ex: Mylanta, Rolaids, Tums, etc)
Dispo: As long as uncomplicated (no bleed, obstruction, perforation, etc), can be discharged from ED with Rx for meds above and referral to PCP or GI.
Gastritis
- Not the same as PUD
- Acute or chronic inflammation of gastric mucosa (not discrete ulcers)
Causes: ischemia, toxic effects of NSAIDs, steroids, bile, alcohol, H. Pylori, autoimmune processes that destroy gastric parietal cells
Exam: epigastric pain, N/V. Often presents with GIB: hematemesis vs chronic anemia vs melena
References:
Fashner J, Gitu AC. Diagnosis and Treatment of Peptic Ulcer Disease and H. pylori Infection. Am Fam Physician. 2015 Feb 15;91(4):236-42. PMID: 25955624.
Malfertheiner P, Chan FK, McColl KE. Peptic ulcer disease. Lancet. 2009 Oct 24;374(9699):1449-61. doi: 10.1016/S0140-6736(09)60938-7. Epub 2009 Aug 13. PMID: 19683340.
