Peptic Ulcer Disease

The term peptic ulcer refers to both gastric and duodenal ulcers. Association of Helicobacter pylori infection is with about 95% of duodenal ulcers and 80% of gastric ulcers.

Prevalence

Dyspepsia occurs in 40% of the population annually and leads to endoscopy in 1%.

Of those who undergo endoscopy:

About 40% have functional or non-ulcer dyspepsia.

40% have gastro-oesophageal reflux disease (GORD).

13% have ulcer disease.

2% have gastric cancer.

1% have oesophageal cancer.

In the past, duodenal ulcer was 10 times as common in men as in women and gastric ulcer had a male preponderance of 3:2. Now the frequency is much less, largely because of H. pylori eradication and the sex incidence being more even.

A reduction in H. pylori-related peptic ulcers, changing patterns in non-steroidal anti-inflammatory drug (NSAID) use and increasing proton pump inhibitor (PPI) use may have contributed to this.

Causes and origin

H. pylori.

NSAIDs.

Pepsin.

Smoking.

Alcohol.

Bile acids.

Steroids.

Stress.

Changes in gastric mucin consistency (may be genetically determined Defence mechanisms include mucus, bicarbonate, mucosal blood flow and prostaglandins.

Appearance

Manifestations

Symptoms of peptic ulcer disease are sometimes very nonspecific and a diagnosis is unreliable on history alone:

Epigastric pain, usually 1 to 3 hours postprandial – it may sometimes wake the patient in the night, and be relieved by food.

Nausea

Oral flatulence, bloating, distension and intolerance of fatty food – the last is also associated with gallstones.

Heartburn sometimes occurs although it is more typically associated with gastro-oesophageal reflux. A posterior ulcer may cause pain radiating to the back.

Symptoms are relieved by antacids (very nonspecific).

Indications

In uncomplicated cases there is very little to find on examination:

There is often epigastric tenderness.

If gastric emptying is slow, there may be a succussion splash.

Conditions with similar symptoms

Abdominal Aortic aneurysm

GERD/GORD

Gastric Cancer

Gallstones

Pancreatitis/Chronic Pancreatitis

Diverticular disease

Irritable bowel syndrome

Hepatitis

Coronary heart disease

Acute ulcers (at times of severe physiological stress – eg, severe burns/head injury).

Probes

FBC may show evidence of iron-deficiency anaemia.

Testing for H. pylori. Test using a carbon-13 urea breath test or a stool antigen test, or laboratory-based serology where its performance has been locally validated. If re-testing is required, a carbon-13 urea breath test is the chosen test.

Endoscopy: Health guidelines state that endoscopy is not required unless the patient is presenting for the first time above the age of 55, or there are warning signs Irrespective of age, endoscopy is required if there is:

Iron-deficiency anaemia.

Chronic blood loss.

Weight loss.

Progressive dysphagia.

Persistent vomiting.

An epigastric mass.

Previous gastric ulcer.

Previous gastric surgery.

Pernicious anaemia.

NSAID use.

Family history of gastric carcinoma.

Wellness program

Modification of behavior

If drugs are the cause then they should be stopped or replaced but this may not be possible. Being more meticulous about the instructions for taking alendronate or taking NSAIDs including aspirin after food may be required.

Cessation of smoking should be advised if applicable. Smoking increases the risk of peptic ulcer and delays healing as well as opposing the action of H₂-receptor antagonists. It has many effects on other parts of the gut including facilitating gastro-oesophageal reflux.

Healing ulcers – H. pylori-positive

Treatment for H. pylori-associated ulcer disease is mainly directed at eradication of infection.

Healing ulcers – H. pylori-negative, NSAID-induced

The NSAID should be stopped. More than 90% of gastric or duodenal ulcers heal with eight weeks of standard-dose H₂-receptor antagonists – eg, ranitidine 150 mg twice a day if the NSAID is discontinued however, PPI drugs are now the mainstay of treatment rather than H₂-receptor antagonists.

A large randomised trial has not shown any difference in gastric ulcer healing between groups receiving esomeprazole 40 mg, esomeprazole 20 mg and ranitidine.

PPIs are better than standard-dose H₂-receptor antagonists and misoprostol for prevention of duodenal ulcers. Patients with high cardiovascular risk should continue to receive prophylactic low-dose aspirin and full-dose naproxen is the preferred NSAID. Co-therapy with a PPI or misoprostol is recommended for these groups. If patients are unable to tolerate PPI treatment, a systematic review of randomised trials found that double-dose H₂-receptor antagonists reduce risk of both gastric and duodenal ulcers.

H. pylori-negative NSAID-negative ulcer

Ulceration of the gastric or duodenal mucosa in the absence of H. pylori infection and NSAID or aspirin usage is rare. A careful history of the use of NSAIDs and aspirin is very important in any patient presenting with gastro-duodenal ulceration in the absence of H. pylori infection. The patient might be unaware that several drugs obtainable over the counter as well as some herbal medications contain NSAIDs or aspirin.

To exclude the rare conditions that may cause this, such as Zollinger-Ellison syndrome, samples should be taken from the ulcer and surrounding mucosa.

Bleeding ulcers

Early endoscopic intervention with ablative or mechanical treatment to the bleeding vessels is the treatment of choice.

Management of recurrence and its prevention

For gastric ulcer with H. pylori infection, eradication therapy is recommended followed by proof of eradication and repeat endoscopy. This is a consensus statement. If eradication is successful but the ulcer unhealed then malignancy needs to be considered.

Serology tests are applicable only for initial diagnosis, as they remain positive for a long while.

If patients are to be given long-term NSAIDs, a review from Hong Kong suggested that stratification of risk should be used to decide the plan for prevention, and that any patient who has had a peptic ulcer bleed (PUB) or who is put on long-term NSAIDs should be checked for H. pylori infection.

For patients who have relapses, intermittent therapy and annual review are recommended.

Vigilance

Patients should be reviewed at the end of a course of treatment, especially H. pylori eradication, to confirm a satisfactory outcome.

Repeat endoscopy may be required for:

Failure to eradicate symptoms in a duodenal ulcer.

Failure to have eradicated H. pylori.

Follow-up of a gastric ulcer – this requires repeat endoscopy to confirm healing at 6 to 8 weeks along with confirmation of eradication of H. pylori.

NSAID-induced ulcers – these should be treated according to whether they are gastric or duodenal.

Validity of medication

In duodenal ulcer, acid suppression for 4 to 8 weeks produces healing of the ulcer in 69%. This rises by an extra 5.4% with eradication therapy too.

In duodenal ulcer, relapse at 3 to 12 months after treatment is 39% after short-term acid suppression alone but eradication increases this by 52% to 91%.

In gastric ulcer, supplementation of acid suppression with eradication therapy does not improve healing rates but it does reduce relapse so that 3 to 12 months later 45% are free of ulcers after just acid suppression but eradication raises this by 32% to 77%.

In patients taking NSAIDs, eradication did not improve the ulcer healing rate but it did halve the number of endoscopically proven ulcers six months later from 18% to 9%.

Complexities

Haematemesis or melaena are associated with erosion of a large blood vessel and significant haemorrhage.

Urgent admission to hospital is required. In patients whose ulcers have bled, eradication of H pylori is more effective than even long-term acid suppression without eradication.

Perforation of a peptic ulcer causes an severe abdominal infection that may progress to generalised rigidity. In the presence of steroids the symptoms of perforation may be suppressed or absent.

Scarring of the duodenum may lead to pyloric stenosis with vomiting and weight loss but this is rare these days with effective treatment. The classical feature is that the vomit shows food such as tomato skins that were eaten 12 to 24 hours ago.

Adverse reactions to PPIs and H₂-receptor antagonists are usually rare and mild but severe problems can arise. Rare but not serious problems may include taste disturbance, peripheral oedema, photosensitivity, fever, arthralgia, myalgia and sweating. Serious problems include liver dysfunction, hypersensitivity reactions (including urticaria, angio-oedema, bronchospasm, anaphylaxis), depression, interstitial nephritis, blood disorders & skin reactions.

Misoprostol often causes diarrhoea and abdominal pain, especially at higher doses.

outlook

Prognosis is excellent if the underlying cause such as H. pylori infection or drugs can be addressed.

Eradication of H. pylori decreases the ulcer recurrence rate from 60-90% to 10-20%. This is still higher than previously reported and this is thought to be due to an increase in NSAID-related ulcers. The mortality rate is 1 in 100,000.