Peptic Ulcer Disease -...
Transcript of Peptic Ulcer Disease -...
PepticUlcerDiseaseHusamBarakat,MD
AmericanBoardinInternalMedicineAmericanboardinGastroenterology
INTRODUCTION
• Apepticulcerisadefectinthegastricorduodenalmucosathatextendsthroughthemuscularis mucosaintothedeeperlayersofthewall
CLINICALMANIFESTATIONS
• Dyspepsia—Upperabdominalpainordiscomfort• Asymptomatic— Approximately70percent ofpepticulcersareasymptomatic• Ulcercomplications- bleeding- gastricoutletobstruction- penetrationandfistulization- perforation
BLEEDINGDU
LABORATORYFINDINGS
• Mostpatientswithpepticulcershaveanormal completebloodcount.However,patientsmayhaveirondeficiencyanemiaduetogastrointestinalbloodloss
DIAGNOSIS
• Upperendoscopy-
Unintentional weightloss
Progressivedysphagia
Odynophagia
Unexplainedirondeficiencyanemia
Persistentvomiting
Palpablemassorlymphadenopathy
Familyhistoryofuppergastrointestinalcancer
DIAGNOSIS:GU
DIAGNOSIS
• Imaging- CT- Barium
GASTRICULCERONBARIUMMEAL
PERFORATEDGU
ESTABLISHINGTHEETIOLOGY
• TestforHelicobacterpylori- Biopsyureasetesting- Ureabreathtest- Stoolantigen• AssessmentofNSAIDuse• Other:smoking,malignancy,acidhypersecretion
RAPIDUREASETEST
DIFFERENTIALDIAGNOSIS
• Celiac• Gastricmalignancy• Chronicpancreatitis• Biliarydisease• Druginduceddyspepsia
MANAGEMENT
• EradicationofHelicobacterpylori- Allpatientswithpepticulcersshouldbetested forinfectionwith H.pylori andtreated
- Inpatientstreatedfor H.pylori, eradication ofinfectionshouldbeconfirmed fourweeksafterthecompletionoftherapy
MANAGEMENT
• Withdrawalofoffendingorcontributingfactors- Patientswithpepticulcersshouldbeadvisedtoavoidnonsteroidalanti-inflammatorydrugs(NSAIDs)
- Contributingfactorsshouldbeaddressedandtreated(eg,treatingmedicalcomorbidities,poornutritionalstatus,ischemia,smoking)
MANAGEMENT
• Antisecretory therapy- H.pylori-positiveulcer:Inpatientswithuncomplicated duodenalulcers,theprotonpumpinhibitor(PPI),givenfor14days,alongwiththeantibioticregimentotreat H.pylori,isusuallyadequatetoinducehealing,andadditionalantisecretory therapyisnotneededaslongastheyareasymptomaticfollowingtherapy
- Inpatientswithcomplicated duodenalulcers,wesuggestantisecretory treatmentforfourtoeightweeksandinpatientswithgastriculcers,wesuggestantisecretory therapyfor8to12weeks
MANAGEMENT
• Inpatientswithgastriculcers,wediscontinueantisecretory therapyonlyafterulcerhealinghasbeenconfirmedbyupperendoscopy• Cureof H.pylori infectionshouldbeconfirmedfourweeksaftercompletionoferadicationtherapy
MANAGEMENT
• NSAID-inducedulcer- PatientswithNSAID-associatedulcersshouldbetreatedwithaPPIforaminimumofeightweeks
- InpatientswithpepticulcerswhoneedtoremainonNSAIDsor aspirin,maintenance antisecretory therapywithaPPIshouldbeconsideredtoreducetheriskofulcercomplicationsorrecurrence
MANAGEMENT
• Non-H.pylori,non-NSAIDulcers- Inpatientswith H.pylori-negativeulcersthatarenotassociatedwithNSAIDuse,wesuggestPPItherapyforfourtoeightweeksbasedontheulcerlocation(gastricorduodenal)andthepresenceofcomplications
MANAGEMENT
• ENDOSCOPYAFTERINITIALTHERAPY- Duodenalulcers—Giventhelowriskofmalignancyinpatientswithduodenalulcers,arepeatupperendoscopyisnotroutinelyrecommendedafterinitialtreatmentunlesssymptomspersistorrecur
ENDOSCOPYAFTERINITIALMANAGEMENT• Gastriculcers:Wesuggestasurveillanceendoscopy(withbiopsiesoftheulcerifstillpresent)beperformedafter12weeksofantisecretory therapyinpatientswithgastriculcersandanyoneofthefollowing:
●Symptomsdespitemedicaltherapy.●Unclearetiology.●Giantulcer(>2cm).●Biopsiesnotperformedorinadequatesamplingontheindexupperendoscopy(totalof<4biopsiesobtainedfromfourquadrantsoftheulcerandadditionalbiopsiesoftheedgeswithjumboforcepsifthereareendoscopicfeaturesofamalignantgastriculcer).●Ulcerappearssuspiciousformalignancyonindexupperendoscopy(masslesion,elevatedirregularulcerborders,orabnormaladjacentmucosalfolds).●Initialendoscopywasperformedforbleeding.●Risksfactorsforgastriccancer(eg,age>50years, H.pylori,immigrantsfromaregionwithhighprevalenceofgastriccancer[eg,Japan,Korea,Taiwan,CostaRica],familyhistoryofgastriccancer,thepresenceofgastricatrophy,adenoma,dysplasia,intestinalmetaplasia).
MANAGEMENT
• MAINTENANCETHERAPY• -Wecontinuemaintenanceantisecretory therapywithaprotonpumpinhibitorinthefollowinghigh-risksubgroupsofpatientswithpepticulcerdisease:
●Giant(>2cm)ulcerandage>50yearsormultipleco-morbidities●H.pylori-negative,nonsteroidalanti-inflammatorydrug(NSAID)-negativeulcerdisease●Refractorypepticulcer●Failuretoeradicate H.pylori●Frequentlyrecurrentpepticulcers(>2documentedrecurrencesayear)●ContinuedNSAIDuse
COMPLICATIONSOFPUD
• GIbleed• Gastricoutletobstruction• Penetration• Fistulization• perforation
TREATMENTDURINGPREGNANCYANDLACTATION
• Whenpepticulcerdiseaseisdiagnosedinawomanwhoispregnant,thefocusoftreatmentistypicallyacidsuppressionwithaprotonpumpinhibitor(PPI)• If H.pylori ispresent,antimicrobialtreatmentistypicallydeferreduntilafterdelivery• limiteddatawithomeprazoleandpantoprazolesuggestthatexcretioninmilkdoesoccurbutthelevelsarelow
DISEASECOURSE
• Approximately60 percentofpepticulcershealspontaneously• witheradicationof H.pylori infection,ulcerhealingratesare>90percent• Evenwithcontinuedprotonpumpinhibitor(PPI)use,approximately5to30percent ofpepticulcersrecurwithinthefirstyearbasedonwhether H.pylori hasbeensuccessfullyeradicated• Approximately5to10percentofulcersarerefractorytoantisecretory therapywithaPPI• Theriskofcomplications inpatientswithchronicpepticulcerdiseaseis2to3percentperyear.
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