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Peptic Ulcer Disease

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 IIPerforated ulcers: laparoscopy/open patching (3)

INPATIENT CONSIDERATIONS

Admission Criteria/Initial Stabilization

  • Discontinue ulcerogenic agents (e.g., NSAIDs) (1).
  • Bleeding peptic ulcersStable: 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.