dr anjani k jha,resident int medicine,nepal,nomc

1. Approach to the management
of Peptic Ulcer Disease
By: Dr. Anjani kumar jha
1st year resident
Internal medicine
2076/07/25

2. Introduction
• A peptic ulcer is defined as disruption of the
mucosal integrity of the stomach and or
duodenum leading to a local defect or excavation
due to active inflammation.
• Although burning epi-gastric pain exacervated by
fasting and improved with meals is a symptoms
complex associated with PUD, it is now clear that
more than 90% patients with this symptom
complex (dyspepsia) do not have ulcers and that
the majority patients with peptic ulcers may be
asymptomatic.
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10. Incidence
• The prevalence of peptic ulcer 0.1 – 0.2 % is
decreasing in many western countries as a
result of widespread use of H.pylori
eradication therapy but remains high in
developing countries.
• The male to female ratio for duodenal ulcer
varies from 5:1 to2:1 while that for gastric
ulcer is 2:1 or less.
• GU and DU coexists in 10% of patients.
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12. Etiology
• Helicobacter pylori, a spiral, gram negative ,
urease producing bacillus, is responsible for at
least half of all PUD and the majority of ulcers
that are not due to NSAIDs.
• PUD can develop in 15-25%of chronic NSAID
and aspirin users. Past history of PUD, age
>60 yrs, concomitant corticosteroids or
anticoagulant therapy, high dose or multiple
NSAID therapy and presence of serious
comorbid medical illness increase risk for
PUD.
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13. Contd..
• A gastrin secreting tumor or gastrinoma
accounts for <1% of all peptic ulcers.
• Gastric cancer or lymphoma may manifest as a
gastric ulcer.
• When none of these etiologies are evident
,PUD is designated idiopathic.
• Cigarette smoking doubles the risk for PUD; it
delays healing and promotes recurrence.
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15. Clinical features
• Epi-gastric pain described as burning or gnawing
discomfort can present in both DU and GU.
• The discomfort is also described as an ill defined,
aching sensation or as hunger pain.
• The typical pain pattern in DU occurs 90min. To 3
hrs. after a meal and frequently relieved by
antacids or food .
• Pain that awakes the patient from sleep between
midnight and 3am is the most discriminating
symptoms .
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16. Contd..
• The pain pattern in GU patients may actually be
precipitated by food. Nausea and weight loss occur
more commonly in GU patients.
• Endoscopy detects ulcer in less than 30% of patients
who have dyspepsia.
• In physical examination, epi-gastric tenderness is the
most frequent finding in patients with GU or DU.
• Tachycardia and orthostasis suggest dehydration
secondary to vomiting or active GI blood loss .
• A severely tender, board like abdomen suggests a
perforation.
• Presence of a succusion splash indicates retained fluid
in the stomach suggesting GOO.
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17. Complications
• GI bleeding
• GOO
• Perforation
• Pancreatitis
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18. Differential diagnosis
• Functional dyspepsia or essential dyspepsia which refers to
the group of heterogenous disorders charcterised by upper
abdominal pain without the presence of an ulcer.
• GERD
• Proximal GI tumors
• Vascular disease
• Pancreatico-billiary disease(chronic pancreatitis )
• Gastro-duodenal cron’s disease.
• ACS
• Acute cholecystitis
• Cholangitis
• Gastritis
• Gall stone
• Esophagitis
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19. Investigations
• Endoscopy provides the most sensitive and
specific approach for examining the upper GI
tract .
• Gastric ulcer can occasionally be malignant
and therefore most always be biopsied and
followed up to ensured healing. Patient should
be tested for H. pylori infection.
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31. Monitoring/ follow up
• Repeat EGD or upper GI series should be
performed 8-12 weeks after initial diagnosis of
all gastric ulcers to document healing; repeat
endoscopic biopsy should be considered for
non-healing ulcers to exclude the possibility
of a malignant ulcer.
• Duodenal ulcers are almost never malignant;
therefore ,documentation of healing is
unnecessary in the absence of symptoms.
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32. References
• Harrisons principles of internal medicine , 20th
edition.
• Davidson principles and practice of medicine ,
23rd edition.
• Washington manual of medical therapeutics
,35th edition.
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33. Thank you!!!
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