Resident Editor: Adam Tabbaa, MD

Faculty Editor: Aparajita Singh, MD, MPH

Background:

• Definition: ulcerations in the stomach and duodenum
• Location: 80% of PUD are duodenal (DU), 20% are gastric (GU)
• Principal risk factors: H. pylori infection and NSAIDs
• Complications if untreated: GI bleed, perforation, gastric outlet obstruction due to ulcer-induced fibrosis

Signs and Symptoms

• Symptoms: epigastric pain relieved by antacids, nausea, vomiting, bloating, early satiety, weight loss, melena
• Physical Exam: Can be normal or have epigastric tenderness, melenic stools

Differential Diagnosis:

• H. Pylori is more commonly seen with DU than GU
• Other risk factors: critical illness, cocaine use, methamphetamine use, smoking, Zollinger-Ellison Syndrome, renal failure, hyperparathyroidism, ischemia
• Crohn’s disease, lymphoma, sarcoid and malignancy may have appearance of peptic ulcer and should be suspected in patients without above risk factors for PUD
• Alcohol, spicy food and caffeine can cause dyspepsia and worsen the symptoms of PUD but they have not been consistently found to be causative factors for PUD
• Steroid use alone does not seem to cause PUD but risk is increased when used in combination with NSAIDs

Evaluation

• There are two major considerations in diagnosis of PUD: determining whether dyspeptic symptoms are due to PUD and identifying the specific etiology of PUD. Note: symptoms or exam alone cannot reliably distinguish PUD from other causes of dyspepsia. 

1) Upper Endoscopy (EGD):  If PUD is suspected, endoscopy is the current standard test for diagnosis.  EGD is expensive and mostly requires sedation.

a. Indications: alarm symptoms or older patients > 55 yrs

b. Therapy: intervention on bleeding ulcers, biopsies for H. pylori and rule out malignancy

c. About 5-10% of GUs can be malignant, and biopsy should be considered in GUs at EGD.

d. Large ulcers with irregular thickened margins are more likely to harbor malignancy, but rarely can be present in small benign appearing GUs as well.

e. Unlike GUs, DUs are extremely unlikely to be malignant and routine biopsy of these ulcers is not recommended.

2)  In younger patients without alarm symptoms, empiric testing for H. pylori and stopping NSAIDs are appropriate first steps. (refer to chapter on H. pylori)

3)   Barium upper GI study: Has limited role in modern practice.  It has low sensitivity for small ulcers.  It is noninvasive, less expensive, does not require sedation. It has some role in stable patients who have significant cardiopulmonary risk factors for sedation.  

Treatment:

• High dose PPI (taken 30 min before meals) twice daily for 4-6 weeks for uncomplicated ulcers.
• Treatment for H. pylori if present (refer to chapter on H. pylori)
  • ACG Guideline updates from 2017 focus on prior antibiotic exposure, local resistance patterns, and advocates for use of quadruple therapy in these select patients
• Avoid/stop NSAIDs

• No firm dietary or psychosocial recommendation is necessary for healing, but patients should avoid food that precipitate symptoms

Follow up:

• Maintenance H2 blocker or low dose PPI (in higher risk) should be considered if:

• H/o complications, frequent recurrence, refractory or giant or severely fibrosed ulcer, fail to eradicate H. pylori
• Underlying cause cannot be reversed or need to continue NSAIDs

• Duration of maintenance therapy is not clear, probably two years or longer
• For H. pylori positive patients, breath or stool antigen test 4-8 weeks after completion of therapy to confirm H. pylori eradication.  
• Taper PPI gradually and do not stop abruptly to prevent rebound acid-hypersecretion.  
• Follow up endoscopy:
  • Not needed in asymptomatic DU patients as malignancy is extremely rare in DU
  • Some GU patients need follow-up EGD within 2-3 months to rule out malignant ulcers if no clear etiology was found or biopsies not done initially
  • Refractory symptoms despite treatment

Prevention:

• Growing data that testing and treating (if positive) for H. pylori prior to beginning long term NSAID use should be considered

When to refer:

• Refer to GI for endoscopy if you suspect PUD (i.e. treatment for non-ulcer dyspepsia and H. pylori does not resolve symptoms: if PPI does not relieve symptoms) or if red flags such as bleeding or weight loss are present.

References

ASGE Standards of Practice Committee. The role of endoscopy in the management of patients with peptic ulcer disease. ASGE Guidelines, 2010. Gastrointestinal Endoscopy. 2010 Apr:71(4):663-8.

Ford AC, et al.  Eradication therapy for peptic ulcer disease in Helicobacter pylori positive patients. Cochrane Database Syst Rev. 2006 Apr 19;(2):CD003840.

Talley NJ; American Gastroenterological Association. American Gastroenterological Association Medical Position Statement: Evaluation of Dyspepsia. Gastroenterology. 2005;129:1753–5

Ramakrishnan K, Salinas RC. Peptic Ulcer Disease. Am Fam Physician. 2007 Oct 1;76(7):1005-12