Peptic ulcer disease and Helicobacter pylori

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Definition of peptic ulcer disease

• Ulceration of the oesophageal, gastric or duodenal mucosa

 

Definition of Helicobacter pylori (H.pylori)

• Gram-negative bacterium found in the stomach and associated with the development of peptic ulcer disease and gastric cancer

 

Epidemiology of peptic ulcer disease

• 1-2/1000 per year. Previously much more common in men, now roughly equal.
• Duodenal ulcers 4 x more common than gastric ulcers

 

Epidemiology of H.pylori

• Prevalence approximately 30% young adults
• Much higher in older people

 

Causes of peptic ulcer disease

• H. Pylori (approximately 80%)
  • Risk factor for:
    • Peptic ulcer disease
    • Gastric cancer (six-fold increased risk)
    • MALT lymphoma (which may regress if H.Pylori is treated)
  • See ‘complications of H.Pylori’ section below for full list of H.Pylori associations

• Drugs
  • Aspirin
  • NSAIDs
  • Steroids
• Smoking
• Alcohol
• Stress
  • Curling’s ulcer (burns – sloughing of mucosa due to plasma loss)
  • Cushing’s ulcer (raised intracranial pressure – changes to vagal tone)
• Acid hypersecretion
  • Zollinger-Ellison – gastrin-secreting tumour (gastrinoma)
    • Responsible for 1/1000. Multiple ulcers.
    • Treat with high-dose PPI (or curative resection)
  • Small bowel resection (loss of negative feedback on acid secretion)
  • Systemic mastocytosis (increase histamine production)
• Abnormal gastric emptying
  • Too fast can give duodenal ulcers
  • Too slow can cause gastric ulcers and succussion splash

 

Presentations of peptic ulcer disease

• Symptoms:
  • Heartburn
  • Dyspepsia (burping, distension, bloating) – either before or after meals
  • Symptoms relieved by antacids
  • Pain
    • Epigastric
    • Posterior in a posterior ulcer
  • Haematemesis or melaena
  • Anterior duodenal ulcers tend to bleed, posterior ulcers are more likely to perforate than anterior ulcers
  • ALARM symptoms (see dyspepsia section)
• Signs:
  • Sometimes epigastric tenderness
  • Succussion splash if gastric emptying delayed

 

 

Differential diagnosis of peptic ulcer disease (see dyspepsia section)

• Oesophagitis/Gastritis
  • Alcohol; NSAIDs; Stress
  • Hiatus hernia
  • Barrett’s oesophagus
• GORD (Gastro-Oesophageal Reflux Disease)
• Malignancy
• Oesophageal spasm
• Biliary causes
• Other causes of upper abdominal pain – angina; AAA; musculoskeletal; pancreatitis

 

 Initial management of peptic ulcer disease and H. pylori infection

• Lifestyle advice
  • Weight loss; smoking cessation; avoid precipitants; raise the head of the bed; don’t eat late at night
  • Stop NSAIDs / bisphosphonates / steroids
  • Use of antacids (eg. Gaviscon, Peptac) PRN.
• Trial of full-dose proton pump inhibitor (PPI) for 4-8 weeks for patients with GORD symptoms.
• Offer H2 blocking therapy therapy (e.g. Ranitidine 150mg once to twice daily) if inadequate response to PPI.
• Test for Helicobacter pylori (H. pylori) if symptoms persist (see below for testing methods):
  • Treat H. pylori if positive or if endoscopic evidence of PUD
  • Eradication therapy
    • Amoxicillin 1g twice daily and Clarithromycin 500mg twice daily plus full-dose PPI for 7 days.
    • If allergic to penicillin then substitute Clarithromycin 250mg and Metronidazole 400mg both twice daily.
• Upper GI endoscopy if symptoms persist despite above
• Urgent (within 2 weeks) upper GI endoscopy if:
  • ALARMS symptoms present
  • Age < 55
    • High risk i.e. previous gastric surgery; FHx gastric malignancy

 

Further management of peptic ulcer disease

• If patients present with an acute upper GI bleed secondary to PUD then manage as per any other GI bleed (see upper GI bleed section)
• H.pylori testing:
  • Allow a 2 week washout period after stopping the PPI before testing for H.Pylori
  • Options:
    • C13-Urea breath test is the best first line test
    • Stool antigen test
      • Both have sensitivity and specificity of approximately 95%
    • Serology
      • Sens 95%, spec only 85%
      • Cannot confirm eradication with it and persistent response
    • Endoscopy and biopsy with rapid urease test (also known as CLO test) is routinely performed at endoscopy

 

Complications of peptic ulcer disease and H. pylori

• Haemorrhage:
  • Controlled endoscopically
  • Adrenaline, diathermy, laser coagulation, heat probe.
  • Bleeding ulcer base can be undersewn by surgeons
• Perforation:
  • Conservative approach (NBM, NG, IV antibiotics) can prevent surgery in up to 50%, if no generalised peritonitis present
  • Laparoscopic repair of hole
• Pyloric stenosis (late complication – lots of vomiting):
  • Balloon dilatation + PPIs
  • If ineffective, drainage procedure (e.g. pyloroplasty)
• MALT lymphoma:
  • B-cell
  • Metastases are rare
  • Associated with paraproteins and pseudohyponatraemia
  • H.Pylori eradication leads to regression in 80%
• Gastric cancer:
  • VacA and CagA strains of H pylori appear to be associated with an increased risk of gastric cancer

 

Prognosis of peptic ulcer disease

• Good, if underlying cause addressed.
  • Approximately 2% recurrence rate
  • Smoking, ETOH, NSAIDs increases recurrence rate (especially gastric ulcers)

 

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