para>PPIs are not associated with an increased risk for major congenital birth defects, spontaneous abortions, or preterm delivery. ‚
Breastfeeding
Both ranitidine and esomeprazole are secreted in breastmilk; however, at considerably lower doses than those used for treatment in infants with reflux disease. Use in breastfeeding women is generally safe (7). ‚
SURGERY/OTHER PROCEDURES
- Endoscopy is indicated for patients age >50 years with new onset of dyspeptic symptoms, those who do not respond to treatment, and those of any age with alarm symptoms, such as bleeding and weight loss (8)[B].
- At endoscopy:
- Biopsy stomach for H. pylori testing (CLO test).
- Biopsy margin of gastric ulcer to exclude malignancy.
- Interventions to stop active bleeding or prevent rebleeding in those with certain stigmata include injection with epinephrine, heater probe treatment, or placement of endoscopic clips (3).
- Indications for surgery: Ulcers that are refractory to treatment and patients at high risk for complications (e.g., transplant recipients, patients dependent on steroids/NSAIDs); surgery also may be needed acutely to treat perforation and bleeding refractory to endoscopic therapy (8).
- Surgical options:
- Duodenal ulcers: truncal vagotomy and drainage (pyloroplasty/gastrojejunostomy), selective vagotomy (preserving the hepatic and/or celiac branches of the vagus) and drainage, or highly selective vagotomy (3)
- Gastric ulcers: partial gastrectomy, Billroth I or II
- Perforated ulcers: laparoscopy/open patching (3)
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
- Discontinue ulcerogenic agents (e.g., NSAIDs) (1).
- Bleeding peptic ulcers
- Stable: Give PPI to reduce transfusion requirements, need for surgery, and duration of hospitalization (9).
- Unstable: Fluid/packed RBC resuscitation followed by emergent esophagogastroduodenoscopy (EGD); use IV PPI.
- Insufficient evidence for concluding superiority, inferiority, or equivalence of high-dose PPI treatment over lower doses in peptic ulcer bleeding (5)[A]
- Oral PPIs are as effective as IV after endoscopic treatment (9).
- Perforated peptic ulcers: Free peritoneal perforation with bacterial peritonitis is a surgical emergency (3).
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Patient Monitoring
- H. pylori eradication: expected in >90% (with double antibiotic regimen): Confirm eradication by urea breath test.
- Acute duodenal ulcer: Monitor clinically.
- Acute gastric ulcer: Confirm healing via endoscopy after 12 weeks (if biopsy not done initially) to confirm that the lesion is benign.
- Tobacco cessation
PROGNOSIS
After H. pylori eradication (10): ‚
- Low ulcer relapse rate; if relapse, consider surreptitious use of NSAIDs.
- Reinfection rates <1% per year
- Low risk of rebleeding
- Decreased NSAID ulcer recurrence (10)
COMPLICATIONS
- Hemorrhage: up to 25% of patients (initial presentation in 10%)
- Perforation: <5% of patients
- Gastric outlet obstruction: up to 5% of duodenal or pyloric channel ulcers; male predilection found
- Risk of gastric adenocarcinoma is increased in H. pylori " “infected patients (2).
- Refractory peptic ulcer disease (5 " “10% after eradication of H. pylori, or completion of 12 weeks of PPI) (11)
REFERENCES
11 Ramakrishnan ‚ K, Salinas ‚ RC. Peptic ulcer disease. Am Fam Physician. 2007;76(7):1005 " “1012.22 Saad ‚ R, Chey ‚ WD. A clinician 's guide to managing Helicobacter pylori infection. Cleve Clin J Med. 2005;72(2):109 " “110,112 " “113,117 " “118.33 Bertleff ‚ MJ, Lange ‚ JF. Perforated peptic ulcer disease: a review of history and treatment. Dig Surg. 2010;27(3):161 " “169.44 Gill ‚ SK, O 'Brien ‚ L, Einarson ‚ TR, et al. The safety of proton pump inhibitors (PPIs) in pregnancy: a meta-analysis. Am J Gastroenterol. 2009;104(6):1541 " “1545.55 Neumann ‚ I, Letelier ‚ LM, Rada ‚ G, et al. Comparison of different regimens of proton pump inhibitors for acute peptic ulcer bleeding. Cochrane Database Syst Rev. 2013;(6):CD007999.66 Luther ‚ J, Higgins ‚ PD, Schoenfeld ‚ PS, et al. Empiric quadruple vs. triple therapy for primary treatment of Helicobacter pylori infection: systematic review and meta-analysis of efficacy and tolerability. Am J Gastroenterol. 2010;105(1):65 " “73.77 Marshall ‚ JK, Thompson ‚ AB, Armstrong ‚ D. Omeprazole for refractory gastroesophageal reflux disease during pregnancy and lactation. Can J Gastroenterol. 1998;12(3):225 " “227.88 Laine ‚ L, Jensen ‚ DM. Management of patients with ulcer bleeding. Am J Gastroenterol. 2012;107(3):345 " “360.99 Yen ‚ HH, Yang ‚ CW, Su ‚ WW, et al. Oral versus intravenous proton pump inhibitors in preventing re-bleeding for patients with peptic ulcer bleeding after successful endoscopic therapy. BMC Gastroenterol. 2012;12:66.1010 Gisbert ‚ JP, Calvet ‚ X, Cosme ‚ A, et al. Long-term follow-up of 1,000 patients cured of Helicobacter pylori infection following an episode of peptic ulcer bleeding. Am J Gastroenterol. 2012;107(8):1197 " “1204.1111 Yuan ‚ Y, Padol ‚ IT, Hunt ‚ RH. Peptic ulcer disease today. Nat Clin Pract Gastroenterol Hepatol. 2006;3(2):80 " “89.
CODES
ICD10
- K27.9 Peptic ulc, site unsp, unsp as ac or chr, w/o hemor or perf
- K26.9 Duodenal ulcer, unspecified as acute or chronic, without hemorrhage or perforation
- K25.9 Gastric ulcer, unspecified as acute or chronic, without hemorrhage or perforation
- K22.10 Ulcer of esophagus without bleeding
- K26.7 Chronic duodenal ulcer without hemorrhage or perforation
- K26.3 Acute duodenal ulcer without hemorrhage or perforation
- K26.2 Acute duodenal ulcer with both hemorrhage and perforation
- K26.1 Acute duodenal ulcer with perforation
- K26.4 Chronic or unspecified duodenal ulcer with hemorrhage
- K26.0 Acute duodenal ulcer with hemorrhage
- K26.5 Chronic or unspecified duodenal ulcer with perforation
- K25.7 Chronic gastric ulcer without hemorrhage or perforation
- K25.6 Chronic or unsp gastric ulcer w both hemorrhage and perf
- K25.5 Chronic or unspecified gastric ulcer with perforation
- K26.6 Chronic or unsp duodenal ulcer w both hemorrhage and perf
- K25.2 Acute gastric ulcer with both hemorrhage and perforation
- K25.4 Chronic or unspecified gastric ulcer with hemorrhage
- K25.1 Acute gastric ulcer with perforation
- K25.0 Acute gastric ulcer with hemorrhage
- K22.11 Ulcer of esophagus with bleeding
- K25.3 Acute gastric ulcer without hemorrhage or perforation
ICD9
- 533.90 Peptic ulcer of unspecified site, unspecified as acute or chronic, without mention of hemorrhage or perforation, without mention of obstruction
- 532.90 Duodenal ulcer, unspecified as acute or chronic, without hemorrhage or perforation, without mention of obstruction
- 531.90 Gastric ulcer, unspecified as acute or chronic, without mention of hemorrhage or perforation, without mention of obstruction
- 530.20 Ulcer of esophagus without bleeding
- 532.50 Chronic or unspecified duodenal ulcer with perforation, without mention of obstruction
- 531.10 Acute gastric ulcer with perforation, without mention of obstruction
- 533.91 Peptic ulcer of unspecified site, unspecified as acute or chronic, without mention of hemorrhage or perforation, with obstruction
- 532.91 Duodenal ulcer, unspecified as acute or chronic, without mention of hemorrhage or perforation, with obstruction
- 532.60 Chronic or unspecified duodenal ulcer with hemorrhage and perforation, without mention of obstruction
- 532.40 Chronic or unspecified duodenal ulcer with hemorrhage, without mention of obstruction
- 532.30 Acute duodenal ulcer without mention of hemorrhage or perforation, without mention of obstruction
- 532.20 Acute duodenal ulcer with hemorrhage and perforation, without mention of obstruction
- 532.10 Acute duodenal ulcer with perforation, without mention of obstruction
- 531.91 Gastric ulcer, unspecified as acute or chronic, without mention of hemorrhage or perforation, with obstruction
- 531.60 Chronic or unspecified gastric ulcer with hemorrhage and perforation, without mention of obstruction
- 531.50 Chronic or unspecified gastric ulcer with perforation, without mention of obstruction
- 531.40 Chronic or unspecified gastric ulcer with hemorrhage, without mention of obstruction
- 531.20 Acute gastric ulcer with hemorrhage and perforation, without mention of obstruction
- 532.70 Chronic duodenal ulcer without mention of hemorrhage or perforation, without mention of obstruction
SNOMED
- 13200003 Peptic ulcer (disorder)
- 51868009 Duodenal ulcer disease (disorder)
- 397825006 Gastric ulcer (disorder)
- 6129004 Peptic ulcer of esophagus
- 88169003 Peptic ulcer with perforation (disorder)
- 64121000 peptic ulcer with hemorrhage (disorder)
- 61300005 Chronic peptic ulcer with hemorrhage AND perforation (disorder)
- 235691009 Chronic peptic ulcer of duodenum
- 235687004 Acute peptic ulcer of duodenum
- 37442009 Peptic ulcer without hemorrhage AND without perforation
CLINICAL PEARLS
- In patients with PUD, H. pylori should be eradicated to assist in healing and to reduce the risk of gastric and duodenal ulcer recurrence.
- Upper endoscopy is indicated in patients with suspected peptic ulcers who are >55 years of age, those who have alarm symptoms, and those who do not respond to treatment.