Peptic Ulcer, Emergency Medicine

Basics

Description

Produced by breakdown in gastric or duodenal mucosal defenses
Imbalance exists between production of acid and ability of mucosa to prevent damage.

Etiology

Helicobacter pylori:
- Gram-negative spiral bacteria that live in mucous layer
- Responsible for 90 " 95% of duodenal ulcers and 80% of gastric ulcers
- Increases antral gastrin production and decreases mucosal integrity
NSAIDs:
- Interfere with prostaglandin synthesis
- Lead to break in mucosa
Aspirin
Cigarette smoking
Alcohol
Severe physiologic stress
Hypersecretory states (uncommon)
Genetics (>20% have family history)

Diagnosis

Signs and Symptoms

Epigastric pain or tenderness (80 " 90%):
- Burning, gnawing, aching pain
- Location: midline, xiphoid, or umbilicus
Duodenal ulcers:
- Pain occurs 90 min " 3 hr after meals
- Usually awakens patient at night
- Food and antacids relieve pain
Gastric ulcers:
- Pain worsens after meals
- Nausea and anorexia
Difficult to differentiate clinically between gastric and duodenal ulcers
Relief of pain with antacids
Heme-positive stools
Complications of peptic ulcer disease (PUD):
- Acute perforation:
  - Rigid, boardlike abdomen
  - Generalized rebound tenderness
  - Pain radiation to back or shoulder
- Obstruction:
  - Pain with vomiting
  - Succussion splash from retained gastric contents and abdominal distention
- Hemorrhage:
  - Hematemesis
  - Melena
  - Hypotension
  - Tachycardia
  - Skin pallor
  - Orthostatic changes

History

NSAID, Aspirin
Smoking
Previous history of PUD
Family history of stomach cancer
Abdominal pain
Diarrhea
Weakness

Physical Exam

Abdominal pain
Signs of anemia
Guaiac-positive stool

Essential Workup

Careful physical exam including Hemoccult testing and vital signs with orthostatics
For stable patients, oral GI cocktail typically relieves pain:
- Antacid: 30 mL
- Viscous lidocaine: 10 mL

Diagnosis Tests & Interpretation

Lab

Normal lab values in uncomplicated ulcer disease
CBC:
- Low hematocrit with bleeding
- Leukocytosis with perforation/penetration
Amylase/lipase:
- Elevated with perforation/penetration
- Pancreatitis in differential diagnosis
Electrolytes, BUN/creatinine, glucose for critically ill
Type and cross-match for significant blood loss
H. pylori testing (urea breath test, H. pylori antibodies, IgG)

Imaging

Chest radiograph/abdominal series:
- Evaluate for perforations/obstructions

Diagnostic Procedures/Surgery

ECG:
- For elderly patients
- Myocardial ischemia in differential diagnosis
Endoscopy:
- Procedure of choice
- Outpatient unless significant hemorrhage
- Allows for biopsies of gastric/duodenal ulcers for presence of H. pylori
- Detects malignant gastric ulcers
Upper GI series:
- Single contrast barium diagnoses 70 " 80%
- Double contrast diagnoses 90%
Gastrin level is elevated in Zollinger " Ellison syndrome

Differential Diagnosis

Gastroesophageal reflux
Biliary colic
Cholecystitis
Pancreatitis
Gastritis
Abdominal aortic aneurysm
Aortic dissection
Myocardial infarction
Subset with symptoms and no ulcer on endoscopy called nonulcer dyspepsia

Treatment

Pre-Hospital

ABCs
IV fluid resuscitation for hypotensive/shock patients

Initial Stabilization/Therapy

ABCs
Identify ulcer complications (hemorrhage, perforation, obstruction)
Treat hypotension with lactated Ringer/normal saline fluid bolus via 2 large-bore IVs
Type and cross early
Nasogastric tube (NGT) for gastric decompression/check for hemorrhage

Ed Treatment/Procedures

Pain control with antacids (GI cocktail) or IV H2 antagonists
Avoid narcotics " may mask serious illness.
Promotion of ulcer healing:
- Antacids
- H2 antagonists (cimetidine, famotidine, ranitidine, nizatidine):
  - May continue for 2 " 5 yr for ulcer suppression therapy
- Proton-pump inhibitors (PPIs; omeprazole, lansoprazole, or pantoprazole):
  - If H2 antagonists have failed
- Sucralfate
- Prostaglandin congeners (misoprostol)
- Sucralfate, H2-receptor antagonists, and PPIs should not be combined because of lack of documented benefit
Gastric outlet obstruction:
- Decompress stomach with NGT
- IV hydration
Gastric hemorrhage:
- IV fluid resuscitation
- Blood transfusion depending on loss/hematocrit
- Foley catheter to monitor volume status
- GI consultation
Perforation:
- IV hydration
- Foley catheter to monitor hydration status
- Preoperative antibiotics
- Emergency surgical consultation
Treatment of H. pylori infection:
- Invasive or noninvasive testing to confirm infection
- Oral eradication antibiotic therapy options:
  - PPI (omeprazole 20 mg BID or lansoprazole 30 mg PO BID) and 2 antibiotics (clarithromycin 500 mg BID + metronidazole 500 mg BID) for 14 days
  - H2 blocker, bismuth subsalicylate (Pepto-Bismol) + either amoxicillin 1,000 mg BID or tetracycline 500 mg QID in combination with either metronidazole 250 mg QID or clarithromycin 500 mg BID for 14 days
  - Most common regimen: Omeprazole 20 mg or lansoprazole 30 mg + clarithromycin 500 mg and amoxicillin 1 g, all taken twice a day for 2 wk
Stop NSAIDs
Surgical therapy:
- Refractory ulcer
- Complications:
  - Bleeding
  - Perforation
  - Pyloric stenosis

Medication

Bismuth subsalicylate: 2 525 mg tabs PO
Maalox Plus: 2 " 4 tabs PO QID
Misoprostol: 100 " 200 mg PO QID
Mylanta II: 2 " 4 tabs PO QID
Sucralfate: 1 g PO QID for 6 " 8 wk
Famotidine (H2 blocker): 40 mg PO nightly at bedtime (peds: 0.5 " 0.6 mg/kg q12h) for 6 " 8 wk
Nizatidine (H2 blocker): 300 mg PO nightly at bedtime for 6 " 8 wk; 20 mg PO BID (peds: 0.6 " 0.7 mg/kg q12 " 24h) for 2 wk
Ranitidine (H2 blocker): 300 mg PO nightly at bedtime (peds: 5 " 10 mg/kg/24h given q12h) for 6 " 8 wk
Cimetidine (H2 blocker): 400 mg PO BID for 6 " 8 wk
Lansoprazole (PPI): 30 mg PO BID for 2 wk
Pantoprazole (PPI): 40 mg PO daily for 2 wk
Omeprazole (PPI): 20 mg PO BID for 2 wk
Rabeprazole (PPI): 20 mg PO daily for 6 wk
Esomeprazole (PPI): 40 mg daily for 4 wk
H. pylori therapy:
- PPI (omeprazole 20 mg or lansoprazole 30 mg), clarithromycin 500 mg BID for 2 wk, amoxicillin 1 g BID for 2 wk
- For penicillin-allergic patients: PPI + clarithromycin 500 mg BID + metronidazole 500 mg BID for 14 days
- 4-drug therapy: H2 blocker, bismuth subsalicylate (Pepto-Bismol) + either amoxicillin 1,000 mg BID or tetracycline 500 mg QID in combination with either metronidazole 250 mg QID or clarithromycin 500 mg BID for 14 days

First Line
H. pylori eradication regimes:

PPI (omeprazole 20 mg or lansoprazole 30 mg), clarithromycin 500 mg BID for 2 wk, amoxicillin 1 g BID for 2 wk
For penicillin-allergic patients: PPI + clarithromycin 500 mg BID + metronidazole 500 mg BID for 14 days
Sequential 10 day therapy in high prevalence areas:
- Double therapy for 5 days
  - PPI
  - Amoxicillin
- Followed by triple therapy for 5 days
  - PPI
  - Clarithromycin
  - Metronidazole
4-drug therapy: H2 blocker, bismuth subsalicylate (Pepto-Bismol) + either amoxicillin 1,000 mg BID or tetracycline 500 mg QID in combination with either metronidazole 250 mg QID or clarithromycin 500 mg BID for 14 days

Second Line
1 wk quadruple therapy:

Bismuth subsalicylate 120 mg PO QID, tetracycline PO 500 mg QID, metronidazole 400 mg PO QID, esomeprazole 20 mg PO BID
80% eradication rate

Follow-Up

Disposition

Admission Criteria

Gastric obstruction
Perforation
Active upper GI bleed
Melena
Uncontrolled pain
Anemia requiring transfusion

Discharge Criteria

Unremarkable physical exam with normal CBC and heme-negative stools
If heme-positive stools, discharge if stable vital signs, normal hematocrit, and negative NGT aspiration for upper GI hemorrhage

Issues for Referral
Outpatient GI evaluation and endoscopy

Follow-Up Recommendations

High-risk patients include those with the following characteristics:
- Bleeding with hemodynamic instability
- Repeated hematemesis or any hematochezia
- Failure to clear with gastric lavage
- Coagulopathy
- Comorbid disease
- Advanced age
- Patients with ulcer perforation or penetration require operative repair.
All patients require primary care follow-up in 2 " 6 wk to evaluate efficacy of treatment.
Patients >55 yr and patients with severe symptoms should receive GI referral for endoscopy and testing for H. pylori.

Pearls and Pitfalls

H. pylori is the most common cause of PUD.
NSAID-induced PUD is frequently silent.
Dyspeptic symptoms are nonspecific.
Endoscopy is diagnostic and should include H. pylori screening.
Treatment should include H. pylori eradication and H2 blockers or PPIs.
Complications include perforations, hemorrhage, anemia.
Failure to follow up may result in failure to diagnose gastric cancer.

Additional Reading

Chey WD, Wong BC, Practice Parameters Committee of the American College of Gastroenterology. American College of Gastroenterology guideline on the management of Helicobacter pylori infection. Am J Gastroenterol. 2007;102(8):1808 " 1825.
Lanza FL, Chan FK, Quigley EM, et al. Guidelines for prevention of NSAID-related ulcer complications. Am J Gastroenterol. 2009;104(3):728 " 738.
Louw JA, Marks IN. Peptic ulcer disease. Curr Opin Gastroenterol. 2004;20(6):533 " 537.
Malfertheiner P, Chan FK, McColl KE. Peptic ulcer disease. Lancet. 2009;374:1449 " 1461.
Smoot DT, Go MF, Cryer B. Peptic ulcer disease. Prim Care. 2001;28(3):487 " 503.
Yuan Y, Padol IT, Hunt RH. Peptic ulcer disease today. Nat Clin Pract Gastroenterol Hepatol. 2006;3(2):80 " 89.

Codes

ICD9

531.30 Acute gastric ulcer without mention of hemorrhage or perforation, without mention of obstruction
532.30 Acute duodenal ulcer without mention of hemorrhage or perforation, without mention of obstruction
533.90 Peptic ulcer of unspecified site, unspecified as acute or chronic, without mention of hemorrhage or perforation, without mention of obstruction
532.10 Acute duodenal ulcer with perforation, without mention of obstruction
531.00 Acute gastric ulcer with hemorrhage, without mention of obstruction
531.01 Acute gastric ulcer with hemorrhage, with obstruction
531.0 Acute gastric ulcer with hemorrhage
531.10 Acute gastric ulcer with perforation, without mention of obstruction
531.11 Acute gastric ulcer with perforation, with obstruction
531.1 Acute gastric ulcer with perforation
531.20 Acute gastric ulcer with hemorrhage and perforation, without mention of obstruction
531.21 Acute gastric ulcer with hemorrhage and perforation, with obstruction
531.2 Acute gastric ulcer with hemorrhage and perforation
532.00 Acute duodenal ulcer with hemorrhage, without mention of obstruction
532.01 Acute duodenal ulcer with hemorrhage, with obstruction
532.0 Acute duodenal ulcer with hemorrhage
532.11 Acute duodenal ulcer with perforation, with obstruction
532.1 Acute duodenal ulcer with perforation
532.20 Acute duodenal ulcer with hemorrhage and perforation, without mention of obstruction
532.21 Acute duodenal ulcer with hemorrhage and perforation, with obstruction
532.2 Acute duodenal ulcer with hemorrhage and perforation
532.31 Acute duodenal ulcer without mention of hemorrhage or perforation, with obstruction
532.3 Acute duodenal ulcer without mention of hemorrhage or perforation
533.00 Acute peptic ulcer of unspecified site with hemorrhage, without mention of obstruction
533.10 Acute peptic ulcer of unspecified site with perforation, without mention of obstruction
533.20 Acute peptic ulcer of unspecified site with hemorrhage and perforation, without mention of obstruction
533.21 Acute peptic ulcer of unspecified site with hemorrhage and perforation, with obstruction
533.2 Acute peptic ulcer of unspecified site with hemorrhage and perforation

ICD10

K25.3 Acute gastric ulcer without hemorrhage or perforation
K26.3 Acute duodenal ulcer without hemorrhage or perforation
K27.9 Peptic ulc, site unsp, unsp as ac or chr, w/o hemor or perf
K26.1 Acute duodenal ulcer with perforation
K25.0 Acute gastric ulcer with hemorrhage
K25.1 Acute gastric ulcer with perforation
K25.2 Acute gastric ulcer with both hemorrhage and perforation
K26.0 Acute duodenal ulcer with hemorrhage
K26.2 Acute duodenal ulcer with both hemorrhage and perforation

SNOMED

13200003 Peptic ulcer (disorder)
235687004 Acute peptic ulcer of duodenum
235647009 Acute peptic ulcer of stomach
79118000 Acute peptic ulcer with perforation (disorder)
196687006 Acute peptic ulcer with obstruction (disorder)
64121000 peptic ulcer with hemorrhage (disorder)

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