Peptic Ulcer Disease & Gastritis
Peptic Ulcer Disease
- Chronic illness, recurrent ulcers in stomach and duodenum
- Commonly due to H. Pylori (more on this next week!) and NSAIDs
- Protective factors: prostaglandin, mucus, and bicarb production
- 10% people in the western world will have this in their lifetime
- Sx: 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
- Exam: for uncomplicated PUD, expect benign physical exam +/-epigastric tenderness (not sensitive or specific). VS should be normal.
- 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: endoscopy
- Stop NSAIDs
- Proton pump inhibitors, H2 receptor antagonists, sucralfate, and antacids
- PPI: 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
- 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
1. 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.
2. 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.