Chapter 41. Peptic Ulcer Disease and Gastritis

Peptic ulcer disease (PUD) is a chronic illness manifested by recurrent ulcerations in the stomach and duodenum. Acid and pepsin are crucial for ulcer development, but the great majority of ulcers are directly related to infection with Helicobacter pylori or nonsteroidal anti-inflammatory drug (NSAID) use. Gastritis is acute or chronic gastric mucosal inflammation and has various causes. Dyspepsia is upper abdominal discomfort with or without other symptoms that can have various causes or be functional.

PUD typically presents with burning epigastric pain, though it may be described as sharp, dull, an ache, or an “empty” or “hungry” feeling. It may be relieved by the ingestion of food, milk or antacids, presumably due to an acid buffering or dilution effect. The pain recurs as the gastric contents empty and the recurrent pain classically awakens the patient at night. Atypical presentations are common in the elderly and may include no pain, pain that is not relieved by food, nausea, vomiting, anorexia, weight loss, and/or bleeding.

A change in the character of the pain may herald the onset of a complication. Abrupt onset of severe pain is typical of perforation with spillage of gastric or duodenal contents into the peritoneal cavity. Back pain may represent pancreatitis from a posterior perforation. Nausea, vomiting, early satiety and weight loss may occur with gastric outlet obstruction or cancer. Vomiting blood or passing melanotic stools with or without hemodynamic instability represent a bleeding complication.

PUD cannot be definitively diagnosed on clinical grounds, but it can be strongly suspected in the presence of a “classic” history (as above) accompanied by “benign” physical examination findings and normal vital signs with or without mild epigastric tenderness. Examination findings that may be indicative of PUD complications include: a rigid abdomen consistent with peritonitis in perforation; abdominal distension and succussion splash consistent with gastric outlet obstruction; occult or gross rectal blood or blood in nasogastric aspirate consistent with bleeding.

The differential diagnosis of epigastric pain is extensive. Pain radiating into the chest, water brash, and belching may point to gastroesophageal reflux disease; more severe pain in the right upper quadrant (RUQ) radiating around the right side with tenderness suggests cholelithiasis or biliary colic; pain radiating into the back is common with pancreatitis and a concomitant mass may represent a pseudocyst or if the mass is pulsatile it could represent an abdominal aortic aneurysm. Chronic pain, anorexia, and weight loss with or without a mass may represent cancer. Myocardial ischemia may present as epigastric pain and should be strongly considered in the appropriate clinical setting.

Some ancillary tests may be helpful to exclude PUD complications and to narrow the differential. A normal CBC rules out chronic (but not acute) bleeding. Elevated liver enzymes may indicate hepatitis and elevated lipase may indicate pancreatitis. An upright CXR may show the free air of a perforation and an abdominal US examination may show cholecystitis, cholelithiasis, or an abdominal aortic aneurysm. An ECG and troponin are indicated if myocardial ischemia is suspected.

The gold standard for diagnosis of PUD is visualization of an ulcer by upper GI endoscopy. Endoscopy is indicated in most patients with upper GI bleeding and in any patient with certain “alarm” features consistent with cancer: age >55 year, unexplained weight loss, early satiety or anorexia, persistent vomiting, dysphagia, anemia, abdominal mass, or jaundice. Because of the strong association of H pylori infection with PUD, testing for the presence of H pylori is usually indicated, but this is generally more appropriate at the time of follow-up.

After PUD is diagnosed, the goal of treatment is to heal the ulcer while relieving pain and preventing complications and avoiding recurrence. If the patient is infected with H pylori then it must be eradicated in order to prevent ulcer recurrence. NSAIDs should be stopped whenever possible.

1. Proton pump inhibitors (PPIs) heal ulcers faster than other therapies and also have an inhibitory effect on H pylori. PPIs should be taken about 30 to 60 min prior to a meal. Include: omeprazole 20 to 40 milligrams daily; esomeprazole 20 to 40 milligrams daily; lansoprazole 15 to 30 milligrams daily; pantoprazole 20 to 40 milligrams daily; and rabeprazole 20 milligrams daily.

2. Histamine-2 receptor antagonists (H2RAs) inhibit acid secretion and are available over the counter. H2RAs include: cimetidine 200 to 400 milligrams twice a day; famotidine 10 to 20 milligrams twice a day; nizatidine 75 to 150 milligrams twice a day; and ranitidine 75 to 150 milligrams twice a day.

3. Liquid antacids relieve pain and heal ulcers by buffering gastric acid. Due to the minimal side effects of PPIs and H2RAs, liquid antacids are generally used on an as needed basis for pain relief. Typical dosing is 15 mL 1 hour after meals and at bedtime.

4. If present, H pylori infection should be treated, though this would only rarely be initiated in the ED. There are multiple therapies, but the most common is “triple therapy” for 14 days with a PPI, clarithromycin, and either amoxicillin or metronidazole.

5. Patients with complications always require consultation and most require admission for continued treatment. For the treatment of bleeding, see Chapter 39. For perforation provide resuscitation as needed, place a nasogastric tube, start broad-spectrum antibiotics, and obtain immediate surgical consultation. For gastric outlet obstruction provide resuscitation as needed, place a nasogastric tube, and admit for continued treatment.

6. When uncomplicated PUD is suspected in a stable patient, the great majority can be discharged home on a PPI or an H2RA with a liquid antacid for breakthrough pain and with recommendations to follow-up with their primary care provider for further evaluation as indicated. Patients with “alarm” features who are stable enough for discharge, should be referred for endoscopy.

7. Patients should be told that PUD is a presumptive diagnosis and that they should return for further evaluation or treatment if any of the following occur: worsening pain, increased vomiting, hematemesis or melena, weakness or syncope, fever, or chest pain.