Peptic ulcer [disease] is a break in the lining of the stomach (aka stomach ulcer) [or even the first part of the small intestine (aka duodenal ulcer), or the lower esophagus].

• Upper abdominal pain, causing:
  • Waking up at night, due to pain
  • Pain improves w/ eating
  • Burning or dull aching pain
  • Gastric ulcer would give epigastric pain DURING the meal, as gastric acid production is increased as food enters the stomach
  • Duodenal ulcers would initially be RELIEVED by a meal, as the pyloric sphincter closes to concentrate the stomach contents, thus acid is not reaching the duodenum. Duodenal ulcer pain would manifest mostly 2-3 hours AFTER the meal, when teh stomach begins to release digested food and acid into the duodenum
• Belching
• Vomiting
• Weight loss
• Poor appetite
• Asymptomatic (33% of older Pt's)

• H pylori, bacteria, which increases risk w/ alcohol consumption
• NSAID's, especially sensitive in older Pt's
• Less commonly:
  • Tobacco smoking
  • Malignancy (gastric cancer)
  • Stress due to serious illness
  • Crohn disease
  • Liver cirrhosis

• Suspected clinically
• Confirmed, if the Sx don't resolve after a few weeks of Tx, or if the Pt>45yo, or has other Sx e.g. weight loss, because stomach cancer can cause similar Sx, w/:
  • Endoscopy, esophagogastroduodenoscopy (EGD), to directly visuallly identify, the location and severity of an ulcer
  • Barium swallow contrast x-rays
• H pylori can be Dx by:
  • Urea breath test, which uses radioactive carbon to detect H pylori. The Pt will drink a tasteless liquid which contains carbon, that the H pylori bacteria breaks down. After 1 hour, the Pt is asked to blow into a bag that is sealed. if the Pt is infected w/ H pylori, the breath sample will contain radioactive CO2. This can thus help monitor response to Tx used to eradicate H pylori
  • Culture of a biopsy of the stomach from the EDG, although most labs aren't set up to perform a H pylori culture
  • Rapid urease test, to detect urease activity in a biopsy
  • Measure antibody levels in blood, although it is controversial, because it is NOT reliable, because of their inability to distinguish between past exposure to bacteria, and current infection. It can also be falsely negative if taking abx, or PPI's
  • Stool antigen test
  • Histological exam and staining of an EGD biopsy
• CXR, showing "free gas" in the peritoneal cavity. This is because if a peptic ulcer perforates, air will leak from inside the GI tract (which always contains some air) into the peritoneal cavity (which normally NEVER contains air). If the Pt is standing erect for the CXR, the gas will float to a position under the diaphragm

Source: 2010/12/perforated-DU.jpg">Medicalopedia

• Note that diet does NOT cause or prevent ulcers
• Stop smoking
• Stop NSAID's
• Stop alcohol
• Drugs to decrease stomach acid, w/ 4 weeks of Tx initially recommended, including of:
  • PPI's (proton pump inhibitor)
  • H2 blocker
• If due to H pylori, add abx Amoxicillin AND Clarithromycin, although as abx resistance is increasing, Tx may not always be effective
• Endoscopy, for bleeding ulcers, or if unsuccessful, open surgery

• Stomach cancer
• Coronary heart disease
• Gastritis (stomach inflammation)
• Cholelithiasis (gallbladder inflammation)

• GI bleeding (15%), the most common complication. Sudden large bleeding can be life threatening. It occurs when the ulcer erodes one of the blood vessels, e.g. the gastroduodenal artery (i.e. small blood vessel in the abdomen, that supplies blood to the pylorus, that connects the stomach and duodenum)
• GI perforation (perforated ulcer), where an untreated ulcer can burn through the full thickness of the wall of the stomach (or duodenum), allowing digestive juices and food to leach into the abdominal cavity. Perforation at the anterior surface of the stomach causes acute peritonitis, initially chemical, and later bacterial peritonitis. The 1st sign is often sudden intense abdominal pain, an example is Valentino's syndrome (i.e. named after the silent film actor, who experienced this pain before his death). Posterior wall perforation leads to bleeding due to involvement of gastroduodenal artery that lies posterior to the 1st part of the duodenum → can be Dx by erect abdominal/CXR (seeking air under the diaphragm), and Tx requires immediate surgery
• Gastric outlet obstruction

• Affects 4% of the population at any 1 time, and 10% throughout their life time
• Results in 301k deaths per year, although this number is decreasing
• Incidences of perforated uclers is steadily declining, although it still occurs

• Upper GI bleed
• Perforated ulcer