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Peptic ulcer disease and Helicobacter pylori




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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