Peptic Ulcer Disease

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Peptic ulcer disease occurs when there is a break ≥ 5mm in the mucosal lining of stomach, lower oesophagus, or duodenum.

Causes

  • Helicobacter pylori
  • Long term use of NSAIMs e.g. acetylsalicylic acid, ibuprofen, naproxen, indomethacin, etc. 
    • Increases the risk 5 times
  • Long-term use of NSAIMs plus glucocorticoids (prednisolone, hydrocortisone, dexamethasone, and beclomethasone)
    • Increases the risk 10 to 15 times
  • Long-term use of anticoagulants and thrombolytics
  • Selective serotonin reuptake inhibitors (e.g. fluoxetine)
  • Smoking
  • Alcohol use
  • Crohn’s disease

Signs and symptoms

  • Recurrent epigastric or retrosternal pain
  • Weight loss
  • Nausea or vomiting
  • Bloating
  • Early satiety
  • Features of complications
    • Gastrointestinal bleedings: anaemia, haematemesis, melaena, shock
    • Perforation: peritonitis, fever
    • Penetration: Epigastric tenderness
    • Gastric outlet obstruction: distension and vomiting

Differential diagnosis

  • Functional dyspepsia
  • Gastritis
  • Oesophagitis
  • Pancreatitis
  • Gastro-duodenal malignancy
  • Coronary heart disease
  • Gallbladder inflammation

Complications

  • Bleeding
  • Perforation
  • Gastric outlet obstruction

Investigations

  • Gastroscopy
  • Stool for occult blood
  • Barium meal
  • Full blood count

Treatment objectives

  • Eradicate H pylori infection
  • Reduce morbidity
  • Prevent complications 

Pharmacological treatment

First Line

Initially, try antacids

Aluminium hydroxide/magnesium carbonate oral

Adult

500mg at least every 4 hours as required

OR             

Magnesium Trisilicate oral mixture

Adult

20ml 4-6 times a day as required. If symptoms persist, endoscopy is necessary.

 

For confirmed peptic ulcer

Eradication of H. pylori

Omeprazole oral

20 mg two times daily

PLUS

Clarithromycin Oral

500 mg two times daily 

PLUS

Amoxicillin oral

1000 mg two times daily for 14 days

 

Frequent severe recurrent ulcers or patients who must continue with NSAIMS

Test and treat for H. pylori and then commence on long-term NSAIM + maintenance PPI therapy.

Maintenance treatment might be required:

Ranitidine oral

150mg two times a day (or 300 mg at night)

Omeprazole oral

20 mg orally daily

Referral

For persistent non-healing ulcers see a specialist (gastroenterologist; Internal Medicine Specialist; Surgeon Specialist; Radiologist for Barium Meal) for further management

Prevention

  • Reduce coffee consumption
  • Avoid all non-steroidal anti-inflammatory medicines and steroids
  • Avoid selective serotonin reuptake inhibitors (fluoxetine)
  • Encourage relaxation and regular exercise
  • Avoid stress as much as possible
  • Psychosocial counselling