Editing Peptic ulcer disease


An ulcer is "a defect in gastric or intestinal mucosae that extends through the muscularis mucosae"

* i.e. extends into submucosal     layer

== '''Epidemiology''' ==

* Declining incidence in     developed countries
* Declining progression to     complicated PUD
* Ulcers are rare before the     age of 40, and peak incidence is 55-65

== '''Aetiology''' - MINT ==

* Medications
** NSAIDs/aspirin
*** Increased COX-1 inhibition       leads to decreased prostaglandins and therefore impaired mucosal       protection
*** Normally, prostaglandins       protects gastric and duodenal mucosa from luminal acid and pepsin via       increased mucin and bicarbonate secretion and increased mucosal       endothelium blood flow and promoting epithelial cell proliferation and       migration to the luminal surface
*** Risk for mucosal injury is       roughly proportionate to the anti-inflammatory effect associated with       each NSAID
*** Ulcers are more often found       in the stomach (anywhere in stomach)
*** Not typically associated       with gastritis
*** Ulcers do not usually recur       when NSAIDs are discontinued
** Steroids
* Infections
** H . Pylori
*** Separate topic
** Syphilis
** CMV - multiple round,      erythematous, raised lesions in body and antrum, often with 'halo'      pattern
* Neoplasms
** Neoplastic - ZES
*** Separate topic
** Malignancy
*** Extremely rare with       duodenal ulcers, but consider for gastric ulcers (either gastric       adenocarcinoma or metastatic melanoma/breast/lung cancer)
* Trauma
** Smoking
** Physiological stress
** Cocaine/methamphetamine
*** Causes ischaemia
* Prior gastric surgery

== '''Pathophysiology''' ==

* Decreased defensive factors
** Mucosal bicarbonate      secretion
** Mucus production
** Adequate blood flow
** Growth factors
** Cell renewal
** Endogenous prostaglandins
* Increased damaging factors
** Hydrochloric acid secretion      (gastric acid is normally protective, but ulcerogenic in the presence of      a mucosal injury)
** Pepsins
** Chronic alcohol intake
** Smoking
** Duodenal bile reflux
** Ischaemia
** NSAIDs/corticosteroids
** Hypoxia
** H . Pylori

== '''Anatomy''' ==

* Modified Johnson anatomic     classification
* Historically used to guide     aetiology based on location
* Not as relevant now that we     know the majority of ulcers are caused by H. pylori, but can be used to     define what operation should be performed for each ulcer
* 60% of ulcers occur on the     lesser curvature - most occur within 1.5cm of the histologic transition     point between fundal and antral mucosa

== '''Clinical manifestations:''' ==

* Dyspepsia (epigastric     discomfort) (present in 80%)
** Usually mid-epigastric pain      which is quite well localised
** CLASSICALLY occurs 2-5 hours      post-prandially, when acid secretion is maximal, and no food is present
** Frequently relieved shortly      after food/antacid ingestion
** Constant pain suggests      deeper penetration of the ulcer - radiating to back implies posterior      penetration, possibly through to pancreas
** May have non-specific      food-provoked symptoms
*** Nausea/vomiting, early       satiety, belching, fatty food intolerance, reflux in 45%
* Asymptomatic
** About 70%
** More likely to be      asymptomatic in older patients, those on NSAIDs
* Can't differentiate between     gastric and duodenal ulcers clinically
* Symptoms related to     complications
** Bleeding
** Gastric outlet obstruction
** Perforation
* Alarm features (in dyspepsia)
** Unintentional weight loss
** Progressive dysphagia
** Odynophagia
** Unexplained iron deficiency      anaemia
** Persistent vomiting
** Palpable mass or      lymphadenopathy
** Family history of upper GI      cancer

== '''Investigation''' ==

* Endoscopy
** Indications:
*** Any patient with gastric       ulceration on imaging (can be deferred up to 12 weeks post imaging)
*** Any patient with duodenal       ulceration on imaging and 'alarm features' above
** Sensitivity ~90%
* CT can be used to diagnose
* Barium radiography
** Look for barium within the      ulcer crater
** Can miss subtle ulcers
** Misses 50% of duodenal      ulcers
** Can't biopsy
**

== '''Differential diagnosis''' ==

* Gastric malignancy
** 1/3 of ulcers >2cm      harbour malignancy
** Ulcers not healing at 12      weeks should also raise suspicion
** Look for ulcers with      irregular or heaped-up edges
* Coeliac disease
* Chronic pancreatitis
* Biliary disease
* Drug-induced dyspepsia

== '''Workup for cause''' ==

* Careful history - ask about     all risk factors above
* Perform at least two tests     for H. pylori while off PPIs and antibiotics
* Consider urine salicylate     levels for surreptitious aspirin use
* Biopsy ulcer for malignancy
* Fasting serum gastrin level     (off PPI)

== '''Medical management''' ==

=== '''Uncomplicated     PUD (also needed for all other situations below):''' ===

** H . Pylori eradication
*** HP7 - see separate topic
** Avoid NSAIDs/steroids
*** Will need 8 weeks of PPI,       and consider maintenance PPI if need to stay on NSAIDs long-term
** Stop smoking
** Restrict EtOH to one per day
** Antacids
*** See description under       'GORD' topic
*** Mostly replaced by       antisecretory therapy in modern times, but can be used for symptom       control
** Sucralfate
*** See 'GORD' topic
*** Not clearly established to       benefit PUD
** Histamine antagonists
*** See 'GORD'
*** Despite differences in       potency, RCTs have demonstrated that all H2-receptor antagonists result       in healing rates of 70-80% after 4 weeks and 80-90% after 8 weeks
** PPIs
*** See 'GORD'
*** Most potent anti-secretory       agent
*** Healing rate 85% at 4 weeks       and 96% at 8 weeks

=== '''Uncomplicated     gastric ulcers:''' ===

**

=== '''Complicated     gastric ulcers:''' ===

** PPI 8 weeks (often needs      repeat endoscopy to confirm healing before ceasing therapy)

=== '''Uncomplicated     duodenal ulcers:''' ===

** PPI 14 days
** Abx
** If asymptomatic      post-treatment, no further PPI/Abx needed, and can confirm eradication

=== '''Complicated     duodenal ulcers:''' ===

** PPI 8 weeks

=== '''Ulcers     secondary to H. pylori''' ===

** See separate topic

=== '''Ulcers     secondary to NSAIDs''' ===

** PPI (6 weeks if <1cm, 8      weeks if >1cm)
** Cease NSAIDs
** Lifelong PPI if:
*** Persistent ulcer on repeat       scope
*** >2cm ulcer and age       >50 or multiple comorbidities
*** Recurrent peptic ulcers
*** Condition requiring       long-term NSAID use

=== '''Ulcers not     associated with NSAIDs or H. pylori:''' ===

** PPI 4 weeks for duodenal      ulcer, 8 weeks for gastric ulcer
** Repeat endoscopy, especially      for gastric ulcers
** See above workup
** If workup negative, probably      needs lifelong PPI

=== '''Persistent     ulcers at repeat scope''' ===

** Biopsy for malignancy
** Consider medications, H      pylori, smoking, alcohol
** Consider ZES

== '''Prognosis''' ==

* >90% heal with eradication     of h. pylori
* Acid-reducing procedures e.g.     vagotomy probably not helpful - adds risk without improving outcomes

== '''Complications''' ==

=== Common approach to treatment ===

** NBM
** IVF
** PPI (80mg BD either      esomeprazole/pantoprazole)
*** Reduce to 40mg BD when       tolerating PO intake
*** Then reduce to 40mg daily       after 1/12
** ?H. pylori - however can't      really test while bleeding or on PPIs
** Cease NSAIDs/aspirin if      possible - if not possible, eternal PPI

=== '''Perforation     (9%)''' ===

** 60% are duodenal, 20%      antral, 20% gastric
*** Gastric more likely (10%)       to contain malignancy
*** Most gastric perforations       occur along the anterior aspect of the lesser curvature
** Presentation:
*** Phase 1 (0-2 hours)
**** Sudden onset epigastric        pain, becoming more generalised
**** Local chemical peritonitis        - doesn't want to move
**** Presyncope/syncope, weak        pulse, cool extremities, tachycardia
*** Phase 2 (2-12 hours)
**** Pain may improve, but        generalised, worse with movement
**** Peritonitic, rigid,        tympanitic over liver, ileum
*** Phase 3 (>12 hours)
**** Hypotension, CV collapse
** Investigation
*** CXR - free gas in 65%
*** Typical history and CXR       could technically be enough to operate
*** CT if any doubt, preferably       with oral contrast
** Scores
*** Boey
*** PULP (Peptic ULcer       Perforation score)
** Management:
*** 2x peripheral canulas, NBM       + NGT, IVF, IDC, IV PPI, Abx (cover enteric gram negative rods,       anaerobes, mouth flora - i.e. cef/met or piptaz, add in antifungal if       sick), ?ICU, goals of care
*** Medical
**** 'Herman Taylor regimen'        from a paper in 1946
**** Can sometimes be used in        patients <70yo, well, early presentation
**** Only consider in patients        with localised symptoms, in stable condition, and with a contrast study        confirming a sealed leak
**** Close monitoring, serial        exams, NPO + NGT, Abx and PPI
**** Perc drainage PRN
**** Short-term mortality in        patients who need surgery but are not operative candidates is 30-60%
*** Surgical
**** Indications
***** Required in almost all         patients
***** Delay to surgery         increases mortality
***** Be aware that free gas         without peritonism can sometimes be managed non-operatively
**** '''Technique'''
***** Open
****** Upper          midline laparotomy
****** 0-3cm          perforation/easy: take full-thickness transversely-orientated (so as          not to stricture the lumen) interrupted bites with 3/0 PDS, clipped          on artery forceps but not tied. Fashion a pedicle of omentum and flip          it into the defect, then loosely tie the sutures. Leak test. 5L wash          and drain.
******* If           omentum is flimsy, can use mobilised falciform ligament or serosal           patch
******* This           is termed a pedicled (Cellan-Jones) or free (Graham) patch
*******
****** >3cm          perforation/difficult/unable to close with simple omentopexy: '''Choose          between definitive procedure or damage control.'''
******* '''Definitive procedure:''' Likely to be           '''resection +/- diversion'''.
******** Distal            gastrectomy and a Bilroth II or Roux-en-Y reconstruction. '''See            separate topic - 'distal gastrectomy'.'''
******** Greater            curvature - easier to wedge resect back to healthy stomach, may not            need to divert
******** A            large lesser curvature or duodenal ulcer is notoriously difficult -            likely to be distal/subtotal gastrectomy.
******** Repair            and diversion, instead of resection and diversion (I think this is            a suboptimal option) - can form a Roux-en-Y bypass/Bilroth II and            then either staple across the distal stomach with a non-cutting TA            stapler, or tie a 1 PDS suture around the stomach to divert, which            will be expected to eventually give way. Another option is to make            a gastrotomy and then place a mucosal purse-string suture around            the pylorus from internally.
******* '''Damage control:''' If unable to perform a definitive           procedure for patient factors or disease factors, will need to do a           damage-control procedure - drain with Foley catheter, washout,           transfer to UGIS unit. Better to do this than try a complicated           resection and reconstruction on an unwell patient with limited UGIS           experience.
******** Tube            duodenostomy - 16Fr Foley surrounded by a loose purse-string to            support it, with additional peritoneal drainage and NGT
******** Bring            some omentum up to cover the defect too
******** '''Triple-ostomy approach''' sits between damage            control and definitive repair - drainage of the ulcer bed (maybe            with a T-tube or IDC), stomach drainage through a PEG/NGT, and            feeding jejunostomy, ideally with pyloric exclusion to prevent            gastric contents contacting ulcer. If doing this, perhaps better            just formally resecting.
***** Laparoscopic
****** Less          morbidity and wound complications
****** Good          option in stable and well-resuscitated patients with an          easily-accessible perforation
***** Lavage with 5-10L N/S
***** Classically, leave a         drain and NGT for two days then restart PO intake after 48 hours.         Consider CT with PO contrast or methylene blue leak test prior.
***** Empiric antibiotics 3-5         days and H. pylori eradication once tolerating oral intake (may need         longer courses of antibiotics with delayed intervention)
*** Endoscopic therapy is       emerging
** Prognosis
*** 30% 90-day mortality
** Special situations
*** Perforation and bleeding
**** Might be a 'kissing' ulcer        - can enlarge the perforation, suture-transfix the bleeding ulcer, then        close the perforation


=== '''Bleeding     (73%)''' ===

** See 'UGiB' for initial      workup and management, including operative technique

=== '''Gastric     outlet obstruction (3%)''' ===

** See separate topic

=== '''Penetration''' ===

** Refers to penetration      through bowel wall without free perforation or leakage into the      peritoneum
** i.e. fistula into another      organ

=== '''Intractable     PUD''' ===

** Truly intractable PUD is now      rare
** Refer to workup table above
** Consider eventual treatment      with a vagotomy +/- antrectomy

=== '''Elective surgery for PUD''' ===

* Indications:
** H . Pylori cannot be      eradicated
** Cannot be taken off NSAIDs
** Rarer cause of PUD that      can't be fixed
** Patients non-compliant with      antisecretory therapy (controversial)
* See separate topic under     'UGIS operations'

[[Category:UGIS]]