This document discusses peptic ulcer disease (PUD). PUD is characterized by damage to the gastrointestinal tract caused by gastric acid and pepsin. Common symptoms include abdominal pain, dyspepsia, nausea, and vomiting. Diagnosis involves endoscopy, imaging, and tests for Helicobacter pylori infection. Treatment consists of proton pump inhibitors, antibiotics, cytoprotective agents, and diet modifications. Complications can include perforation, penetration, hemorrhage, and obstruction.

2. Definition.
Classification.
Etiology.
Symptoms.
Diagnosis.
Treatment.
Complications.

3. A problem with the gastrointestinal
tract characterized by mucosal
damage secondary to pepsin and
gastric acid secretion.
Contrary to general belief, more
peptic ulcers arises in the
duodenum than in the stomach.

4. 
CLASSIFICATION
According to Localisation.
 Stomach –gastric ulcers.
 Duodenum-duodenal ulcers.
 Oesophagus- oasophageal ulcers.
According to Phase of Disease.
 Acute
 Uncomplete remission.
 Remission.
Association with H.Pylori
o H.Pylori Associated.
o H.Pylori Not Associated.

5. Etiology.
Helicobacter Bacteria.
Drugs – NSAIDS,Corticosteroids.
Hyperacidity eg,Zollingers Ellison .
Lifestyle risks include smoking,Alcohol and
dietary factors .
Heredity .
Association with other diseases or known
factors.

6.  The main symptoms of PUD:
 Recurrent Abdominal pain:
 localization (epigastrium) and radiation,
 character (episodic occurrence), permanent or seasonal
 relationship to food (early, late, nocturnal, hunger).
 Dyspepsia: (vomiting, nausea, heartburn)
 Relieving factors (taking food or soda, spasmolytics, warmly)
 Possible clinical features (weight loss, fever, anorexia, dysphagia).
 Clinical symptoms of PUD:
 - Tender palpation of the abdomen: local pain (tenderness)
 - Local muscular resistance
 - Mendel’s symptom in epigastrium or duodenum bulb projection
point in percussion
 Auscultation of the abdomen: gastric’s down border,
 If the initial clinical presentation suggests the diagnosis of PUD, the
patient should be evaluated for alarm symptoms.
 Anemia, hematemesis, melena, or heme-positive stool suggests
bleeding; vomiting suggests obstruction; anorexia or weight loss
suggests cancer; persisting upper abdominal pain radiating to the
back suggests penetration; and severe, spreading upper abdominal
pain suggests perforation. Patients older than 55 years and those
with alarm symptoms should be referred for prompt upper endoscopy.

7. INVESTIGATION.
Lab Studies
 Obtain a CBC. Check the hemoglobin and hematocrit - anemia.
 Obtain an electrolyte panel - identifying and correcting electrolyte
abnormalities
 Liver function tests may be helpful, when a malignant etiology is suspected.
 A test for H pylori is helpful when the diagnosis of PUD is suspected
Imaging Studies
 Plain abdominal radiographs, contrast upper GI studies (Gastrografin or
barium), and CT scans with oral contrast are helpful.
 Plain radiographs, including the obstruction series (ie, supine abdomen,
upright abdomen, chest posteroanterior), can demonstrate the presence of
gastric dilatation and may be helpful in distinguishing the differential
diagnosis.
Diagnostic Procedures
 Upper endoscopy can help visualize the gastric outlet and may provide a
tissue diagnosis when the obstruction is intraluminal.
 The sodium chloride load test is a traditional clinical nonimaging study that
may be helpful.
 The traditional sodium chloride load test is performed by infusing 750 cc of
sodium chloride solution into the stomach via a nasogastric tube (NGT).
 A diagnosis of GOO is made if more than 400 cc remain in the stomach after 30
minutes.

8. Tests Used in the Diagnosis of Peptic Ulcer
Test Comments
EGD
______________________
Indicated in patients with evidence of bleeding, weight loss, chronicity, or persistent
vomiting; those whose symptoms do not respond to medications; and those older than 55
years
More than 90 % sensitivity and specificity in diagnosing gastric and duodenal ulcers and
cancers
Barium or Gastrografin contrast
radiography (double-contrast hypotonic
duodenography)
Indicated when endoscopy is unsuitable or not feasible, or if complications such as gastric
outlet obstruction suspected
Diagnostic accuracy increases with extent of disease; 80 to 90 % sensitivity in detecting
duodenal ulcers
Helicobacter pylori testing
Serologic ELISA
_____________________
Useful only for initial testing (sensitivity, 85 %; specificity, 79 %); cannot be used to confirm
eradication
Urea breath test
______________________
More expensive, Sensitivity, 95 to 100 %; specificity, 91 to 98 %; can be used to confirm
eradication
PPI therapy should be stopped for 2 weeks before test
Stool antigen test
______________________
Inconvenient but accurate (sensitivity 91 to 98 %; specificity 94 to 99%), Can be used to
confirm eradication
Urine-based ELISA and rapid urine test Sensitivity, 70 to 96 %; specificity, 77 to 85 %
Cannot be used to confirm eradication
Endoscopic biopsy Culture (sensitivity, 70 to 80 %; specificity, 100 %), histology (sensitivity, > 95 %; specificity,
100 %), rapid urease (CLO) test (sensitivity, 93 to 97 %; specificity, 100 %)
EGD = esophagogastroduodenoscopy; ELISA= enzyme-linked immunosorbent assay; PPI= proton pump inhibitor; CLO=
Campylobacter-like organism.

9. Treatment.
1. Antisecretory drugs
• Proton pump inhibitors :Omeprazole(20mg) Lansoprazole(30
mg) Pantoprazole( 40mg) Rabeprazole (20mg) ..all once a day.
H2 receptor antagonists : Cimetidine, Famotidine, Nizatidine
,Rantidine
• Antacids :Amagel,Maalox.
2. Antibiotics :Clarithromycin,Amoxycillini.
3. Cytoprotective agents : Misoprostol, Sucralfate .
4. Diet- it is common sense approach to avoid any
foods and beverages that aggravate the symptoms
alcohol included.

10. Complications.
 Perforation - Involuntary guarding is indicative of
peritonitis secondary to gastric perforation.
 Penetration – is type of the closed Perforation
 Hemorrhage – Upper gastrointestinal bleeding
(UGIB) is a common medical condition that results
in high patient mortality and medical care costs.
 Obstruction - Gastric outlet obstruction (GOO) is
not a single entity; it is the clinical and
pathophysiological consequence of any disease
process that produces a mechanical impediment to
gastric emptying.