pud final 1

Ala’a Al-johani

Tufol Al-zaid

Peptic ulcer disease

(PUD)

objectives:

Definition and pathophysiology.

Causes and risk factors.

Site.

Clinical picture.

Differential Diagnoses

Investigation.

Treatment.

Complication.

Case:

45 year Saudi female complain of Rhumatoid

Arthritis for 10 years ,she is on

methotrexate, naproxen came to Dr.Tufol

complain of recurrent epigastric pain 3-4 hs

after eat and weight gain.

Peptic ulcer disease (PUD) is a common disorder that affects

.millions of individuals worldwide

In the United States, PUD affects approximately 4.5 million

people annually. Approximately 10% of the US population

has evidence of a duodenal ulcer at some time.

The frequency of PUD in other countries is variable and is

determined primarily by association with the major causes of

PUD: H pylori and NSAIDs

Peptic Ulcer

An ulcer of the alimentary tract mucosa, usually

in the stomach or duodenum, & rarely in the

lower esophagus, where the mucosa is exposed to

the acid gastric secretion

Pathophysiology:

Causes:

The two most common causes of PUD are:

Helicobacter pylori infection ( 70-80%)

Non-steroidal anti-inflammatory drugs

(NSAIDS)

Other uncommon causes include:

• Gastrinoma (Zollinger-Ellison

syndrome) (Gastrin secreting tumor)

•Stress ulceration (trauma, burns,

critical illness)

•Viral infection.

•Chemotherapy -Radiotherapy

:Effect of NSAID on GI mucosa

Is there any genetic role in peptic ulcer?

More than 20% of patients have a family history of duodenal

ulcers, compared with only 5-10% in the control groups. In

addition, weak associations have been observed between

duodenal ulcers and blood type O.

A rare genetic association exists between familial

hyperpepsinogenemia type I (a genetic phenotype leading to

enhanced secretion of pepsin) and duodenal ulcers.

risk factors:

Age > 65 years (3.5-fold increased risk)

Alcoholic

Smoking

Past history of peptic ulcer

concomitant corticosteroid use

High dose or multiple NSAID

Medical diagnosis and management (short text book)

Mohmmad inaam danish

2009

Site:

90-95% of duodenal ulcer occure

in the first portion of dudenum

in the anterior wall

duodenum

More than 90% of gastric ulcer

occur in the lesser curvature

Stomach

In reflux oesopgagitis esophagus

In Zollinger-Elison syndrome jejunum

Which contains ectopic gastric

mucosa

Meckle’s diverticulum

Case simulation

• Investigation

I

• observation

O

• Prevention

P

• Advice

A

• Prescription p

• referral

R

• clarification

C

• reassurance

R

Clinical picture

Clinical picture

Epigastric pain

The most common symptom of both gastric and duodenal ulcers.

It is characterized by burning sensation. Pain with radiation to the back is suggestive of a

posterior penetrating gastric ulcer . Abdominal pain is absent in 30% of older patient

with PUD.

2013 , 22 dateNov Upto

2007,01 octAFP

Clinical picture

epigastric pain

Food and antacid provide minimal

relief of pain.

Occurs shortly after meals

Pain not increase at nght.

Gastric ulcer

Food and antacid relief the pain.

Occurs 3-4 hours afterward

Pain awaken patient at night.

Duodenal ulcer

2013 , 22 dateNov Upto

2007,01 octAFP

Clinical picture

Other symptoms of PUD

Dyspepsia , bloating and distention.

Heartburn.

Chest discomfort.

Vomiting.

Fatty food intolerance.

Weight loss due to fear of food is a characteristic

of gastric ulcer.

2013 , 22 dateNov Upto

2007,01 octAFP

Clinical picture

(red flags):

Alarm features that warrant prompt gastroenterology referral:

Hematemesis or melena

hematochezia.

anemia .

Sudden onset of symptoms witch may indicate perforation.

Early satiety.

Recurrent vomiting

Unexplained weight loss

Family history of gastric ulcer.

Medscape Jun 7, 2012

Differential Diagnoses

Differential Diagnoses

Abdominal Aneurysm.

Cholangitis.

Cholecystitis.

Cholelithiasis.

Diverticular Disease.

Esophageal Perforation, Rupture and Tears.

Esophagitis.

Gastritis.

Gastroenteritis.

Gastroesophageal Reflux Disease.

Inflammatory Bowel Disease.

Viral Hepatitis.

Medscape Jun 7, 2012

investigations

Investigation

There are two major considerations in diagnosis of

peptic ulcer disease (PUD):

1. Investigations needed to establish diagnosis of

PUD.

2. Investigation needed to diagnose a cause (

H.pylori infection).

Uptodate Dec 03, 2013

Investigation

FIRST, diagnostic studies in patients who may have a peptic ulcer:

blood tests.

endoscopy (EGD):

1. Detection of ulcer disease ("gold" standard test )

2. Differentiation of benign gastric ulcers from cancer :

Benign ulcers have smooth, regular, rounded edges, with a flat, smooth ulcer

base often filled with exudate

Benign ulcer The ulcerated mass protrudes into

the lumen

The folds surrounding the ulcer crater are nodular

The margins are overhanging, irregular, or thickened

Malignant ulcer

Uptodate Dec 03, 2013

Investigation

Cont. Endoscopy:

3. Follow-up endoscopy to exclude malignant GU.

barium radiography:

1. Detection of ulcer disease

2. differentiation of benign versus malignant lesions:

Uptodate Dec 03, 2013

Investigation

SECOND, HELICOBACTER PYLORI TESTING:

Serology: serum antibody detection, it

is useful only for initial testing ,cannot be

used to confirm eradication because test can

be positive for years even if the infection is

cured.

Urea breath test: can be used to confirm

eradication ( PPI therapy should be stopped

for two weeks before test).

Uptodate Dec 03, 2013

SECOND, HELICOBACTER PYLORI TESTING:

Stool antigen test:

This test can be used to

diagnose the infection

and confirm that it has

been cured after

treatment.

Endoscopic biopsy.

Uptodate Dec 03, 2013

Treatment

treatment First, Eradication of Helicobacter pylori :

Triple therapy:

Omeprazole (20 mg twice daily).

amoxicillin (1 g tewice daily) or metronidazole (500 mg twice daily) -if allergic to penicillin-.

clarithromycin (500 mg twice daily).

quadruple therapy:

Ranitidine bismuth citrate (400 mg twice daily ).

tetracycline (500 mg twice daily) .

metronidazole ( 250 mg four times daily) .

Omeprazole (20 mg twice daily) .

Uptodate april 25,2014

treatment

Second, Cytoprotective agents:

Misoprostol : it is a prostaglandin analog that can be

used to decrease the incidence of peptic ulcers and

complications in long-term NSAID users at high risk.

Sucralfate : it binds with positively charged proteins in

exudates and forms a viscous adhesive substance that

protects the GI lining against pepsin, peptic acid, and bile

salts. It is used for short-term management of ulcers.

Uptodate april 25,2014

Medscape jun 07,2012

treatment

Third, health education:

Not taking (NSAIDs), These include aspirin and ibuprofen .

Avoid steroids.

Quitting smoking.

No special diet is needed, avoid any food or beverages that may aggravate symptoms.

Fourth, surgery: Duodenal ulcer: truncal vagotomy, selective vagotomy, highly

selective vagotomy, partial gastrectomy

Gastric ulcer: partial gastrectomy with gastroduodenal or gastrojejunal anastomosis.

Uptodate april 25,2014

Medscape jun 07,2012

complication

complication

Perforation: more common in DU than GU, and

usually ulcer site is on anterior duodenal bulb.

Bleeding: more common in posterior ulcer (presence

of gastroduodenal artery).

Gastric outlet obstruction.

Malignancy: gastric ulcer have 2-4% risk of

malignancy, multiple biopsies are required at time of

endoscopy.

Uptodate april 25,2014

Medscape jun 07,2012

References…