Gastroenterology · Peptic Ulcer Disease
The facts most likely to be tested
Helicobacter pylori infection is the most common cause of duodenal ulcers, while NSAID use is the most common cause of gastric ulcers.
Duodenal ulcers typically present with epigastric pain that improves with food intake, whereas gastric ulcers present with pain that worsens with food.
Upper endoscopy (EGD) with biopsy is the gold standard diagnostic test to confirm the presence of an ulcer and rule out malignancy in gastric ulcers.
All patients with a confirmed H. pylori infection require quadruple therapy consisting of a proton pump inhibitor (PPI), bismuth subsalicylate, metronidazole, and tetracycline.
Perforation of a peptic ulcer presents with sudden-onset severe abdominal pain, peritoneal signs, and free air under the diaphragm on an upright chest X-ray.
Zollinger-Ellison syndrome should be suspected in patients with refractory ulcers, multiple ulcers, or ulcers distal to the duodenum.
Gastric ulcers require a follow-up endoscopy at 8–12 weeks to ensure complete healing and exclude gastric adenocarcinoma.
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A 58-year-old male presents to the emergency department with sudden-onset, severe epigastric pain that radiates to the back. He has a history of chronic osteoarthritis managed with high-dose naproxen. On physical examination, he is diaphoretic and has a rigid, board-like abdomen with diffuse rebound tenderness. An upright chest X-ray reveals pneumoperitoneum.
What is the most appropriate next step in management?
Emergent surgical consultation
The patient presents with signs of a perforated peptic ulcer (free air under the diaphragm and board-like abdomen), which is a surgical emergency requiring immediate intervention.
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Etiology / Epidemiology
H. pylori infection and NSAID use are the primary drivers of mucosal injury.
Clinical Manifestations
Duodenal ulcers improve with food; gastric ulcers worsen. Dyspepsia is the classic presentation.
Diagnosis
Upper endoscopy is the gold standard for visualization and biopsy.
Treatment
PPIs are first-line; H. pylori requires clarithromycin + amoxicillin + PPI.
Prognosis
Perforation and hemorrhage are life-threatening complications requiring urgent intervention.
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Epidemiology & Etiology
The two most common causes are Helicobacter pylori infection and chronic NSAID use. Other risk factors include smoking, alcohol, and Zollinger-Ellison syndrome. Incidence peaks in the 5th and 6th decades of life.
Pertinent Anatomy
Duodenal ulcers occur most frequently in the duodenal bulb. Gastric ulcers are typically found at the antrum or the junction of the antrum and the acid-secreting body.
Pathophysiology
Ulceration results from an imbalance between aggressive factors (acid, pepsin) and mucosal defense mechanisms (mucus, bicarbonate). H. pylori induces chronic inflammation, while NSAIDs inhibit COX-1, reducing protective prostaglandin synthesis. This leads to mucosal breakdown and potential erosion into submucosal vessels.
Clinical Manifestations
Patients present with epigastric pain described as burning or gnawing. Duodenal ulcers classically improve with meals, whereas gastric ulcers worsen with food intake. Red flag symptoms include weight loss, anemia, melena, and persistent vomiting, which mandate immediate evaluation for malignancy.
Diagnosis
Upper endoscopy with biopsy is the gold standard for diagnosis and ruling out malignancy. For H. pylori, the urea breath test or fecal antigen test are preferred for non-invasive confirmation. Serology is less useful due to inability to distinguish active from past infection.
Treatment
First-line therapy for H. pylori is triple therapy (clarithromycin, amoxicillin, and a PPI) for 14 days. Bismuth subsalicylate is added in quadruple therapy for resistant cases. NSAIDs must be discontinued immediately to allow mucosal healing.
Prognosis
Most ulcers heal with appropriate PPI therapy. Perforation presents with sudden, severe abdominal pain and peritonitis, requiring surgical consultation. Hemorrhage is the most common complication and may require endoscopic hemostasis.
Differential Diagnosis
GERD: retrosternal burning, not epigastric
Gastric cancer: weight loss, early satiety, iron deficiency anemia
Cholelithiasis: RUQ pain, postprandial, triggered by fatty foods
Pancreatitis: radiating back pain, elevated lipase
Non-ulcer dyspepsia: diagnosis of exclusion after negative endoscopy