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Peptic ulcer disease 

Peptic ulcer disease

Chapter:
Peptic ulcer disease
Author(s):

Joseph Sung

DOI:
10.1093/med/9780199204854.003.1508_update_002

Update:

Chapter reviewed, minor changes made, further reading added.

Updated on 27 Nov 2014. The previous version of this content can be found here.
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date: 28 April 2017

Helicobacter pylori infection and the use of nonsteroidal anti-inflammatory drugs (NSAIDs) including aspirin are the most important causes of peptic ulcer disease. Cigarette smoking also increases the risk, but—although often alleged—there is little evidence to implicate psychological stress. Zollinger–Ellison syndrome, which consists of a gastrin-secreting islet cell tumour (gastrinoma) leading to marked hypergastrinemia, is a rare cause of recurrent peptic ulceration.

Peptic ulcer disease is characterized by a history of waxing and waning symptoms of localized, dull, aching pain in the upper abdomen. Bleeding is the most common complication. Free perforation of the stomach or duodenum into the peritoneal cavity is an uncommon but serious complication.

The diagnosis of peptic ulcer disease is made by endoscopy, which can (1) confirm the diagnosis of peptic ulcer; (2) offer an opportunity for biopsy of gastric ulcers, which may be malignant; and (3) reveal important prognostic indicators in patients with bleeding ulcers (Forrest classification: grade I ulcers are those with active bleeding; grade II have signs of recent bleeding; grade III have a clean base).

A single daily dose of a proton pump inhibitor gives quick relief of symptom and effective healing of peptic ulcers in 4 to 6 weeks. These drugs are more effective than misoprostol and H2-receptor antagonists in healing ulcers, as well as in preventing further peptic ulcerations and erosions.

The management of patients with upper gastrointestinal haemorrhage requires a multidisciplinary medical and surgical approach. Upper gastrointestinal bleeding stops spontaneously in about 80 to 85% of patients, but the remaining 15 to 20% continue to bleed or develop recurrent bleeding, and these patients constitute a high-risk group with substantially increased morbidity and mortality. Early risk stratification based on clinical and endoscopic criteria allows delivery of appropriate care, with endoscopic intervention (endoscopic injection, thermal coagulation, or mechanical haemostasis, i.e. clipping or banding) now widely accepted as the first line of therapy. This should be applied to actively bleeding ulcers or ulcers covered with an adherent clot to reduce both recurrent bleeding and the need for surgical intervention, and be followed by administration of a high dose of intravenous proton pump inhibitor to further reduce recurrent bleeding.

Treatment of H. pylori is a cure for peptic ulcer disease in most patients with the condition. Many antimicrobials can be effective, but successful cure usually requires at least two antimicrobial agents, with the most popular triple therapy combining a proton pump inhibitor with any two of amoxicillin, metronidazole, and clarithromycin for 7 to 14 days. Eradication of H. pylori can be confirmed by either urea breath test, stool antigen test, or biopsy urease test, which should be done at least 4 weeks after finishing the anti-helicobacter regimen and discontinuation of the proton pump inhibitor for at least 2 weeks.

Eradication of H. pylori infection, avoidance of high-dose NSAIDs or aspirin, and the maintenance use of proton pump inhibitors in high-risk individuals are the best ways to prevent recurrence of ulcer and ulcer complications.

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