Diagnosis

Ulcer disease

Etiology

Cause [huc]

• Gastric acid or pepsin cases the damage

• Co-factors are usually essential to the mucous injury:

  • H.pylori (responsible for 90% of duodenal ulcers and ~80% of gastric ulcers)

  • Drug side effects: NSAIDs, SSRIs, corticosteroids, anticoagulants, bisphosphonates

  • Other rare causes:

    • Zollinger-Ellison syndrome

    • Malignancy (gastric/lung cancer, lymphomas)

    • Stress (acute illness, burns, head injury)

    • Viral infection

    • Vascular insufficiency

    • Radiation therapy

    • Crohn disease

    • Chemotherapy

Pathophysiology

1. Mucosal injury and peptic ulcer occur when the balance between the aggressive factors and the defensive mechanisms is disrupted

   • Aggresive factors: H.pylori, drug side effects (NSAIDs, SSRIs, corticosteroids, and anticoagulants), bile salts, smoking, alcohol, Zollinger-Ellison syndrome

   • Defensive mechanisms: bicarbonate secretion, mucus, mucosal blood flow, epithelial renewal

2. Once the protective superficial mucosal layer is damaged, the inner layers are susceptible to acidity

3. Helicobacter Pylori --> mucosal inflammation and host tissue damage

4. NSAIDs --> inhibit COX-enzyme --> block prostaglandin synthesis --> decreased gastric mucus and bicarbonate production and a decrease in mucosal blood flow

5. Alcohol --> irritate the gastric mucosa and induce acidity

6. Hypersecretion of acid:

   • Zollinger Ellison syndrome

   • Systemic mastocytosis

   • Cystic fibrosis

   • Hyperparathyroidism

   • Antral G cell hyperplasia

7. Clinical manifestation:

   • Epigastric abdominal pain

   • Bloating/dysphagia

   • Abdominal fullness

   • Nausea and vomiting

   • Weight loss/weight gain

   • Hematemesis

   • Melena

Complications [huc]

• Bleeding

• Perforation

• Gastric cancer

• Stenosis (Gastric outlet obstruction)

Epidemiology

Incidence per 100.000 [wz9][gt9][onf][ygn][9pi][yyw][8an][9p6]

Approach

• Blood test: Hb, liver function, amylase and lipase

• Hemofec

• Gastroscopy

• Helicobacter pylori testing:

  • Serelogy

  • Urea breath test (high sensitivity and specificity)

  • Antibodies to H.pylori

  • Stool antigen test

  • Urine-based ELISA and rapid urine test

  • Endoscopic biopsy

• CT abdomen if complications (perforation, GI obstruction)

Treatment

1. Lifestyle changes: NSAIDs, smoking, alcohol consumption [huc]

2. Antisecretory drugs: Proton pump inhibitor (PPI), H2 blocker

3. Eradication of H.pylori -> triple regimen comprising two antibiotics and a PPI:

   • Pantoprazole, clarithromycin, and metronidazole/amoxicillin for 7 to 14 days

   • If failure to response: Quadruple therapy with bismuth

4. Surgical treatment: if unresponsive to medical treatment

   • Vagotomy or partial gastrectomy

Differential diagnoses

Acute pancreatitis, Aortic dissection, Arteriovenous malformation, Cholangitis, Cholecystitis, Cholelithiasis, Chronic mesenteric ischemia, Chronic pancreatitis, Colorectal cancer, Crohn disease, Diverticulitis, Drug side effects, Esophageal perforation, Esophageal varices, Esophagitis, Functional dyspepsia, Gastric cancer, Gastritis, Gastroenteritis, Gastroesophageal reflux disease, Gastrointestinal obstruction, Gastrointestinal perforation, Hemobilia, Mallory-Weiss tear, Myocardial infarction, Perforated ulcer, Ruptured aortic aneurysm, Ulcerative colitis, Viral hepatitis, Volvulus, Zollinger-Ellison syndrome