Peptic Ulcer Disease

Background

• Peptic ulcer disease (PUD) involves the development of mucosal defect(s) in the gastric or duodenal wall that typically extend through the muscularis mucosa (innermost layer of mucosa) into deeper layers of the wall (submucosa or muscularis propria).
• Most peptic ulcers are caused by Helicobacter pylori infection or nonsteroidal anti-inflammatory drugs (NSAIDs), including aspirin.
• Many patients with PUD remain asymptomatic but may present with nonspecific intermittent symptoms of epigastric pain, early satiety, and/or bloating.
• Bleeding is the most frequent and severe complication of PUD. Other complications include perforation, penetration, and development of scarring with gastric outlet obstruction.

Evaluation

• Patients may present with episodic, dyspeptic epigastric pain (often at night with duodenal lesions). Other common symptoms include feelings of hunger, bloating, and nausea/ vomiting.
• Obtain detailed history, including use of nonsteroidal anti-inflammatory drugs (NSAIDs) and past history of peptic ulcer.
• Definitive diagnosis of peptic ulcer disease is based on imaging by upper endoscopy.
  • Factors prompting consideration of initial upper endoscopy include any of the following:
    • age ≥ 50-60 years with new-onset dyspepsia
    • ≥ 1 alarm symptoms, including unintentional weight loss, early satiety, dysphagia or odynophagia, GI bleeding, iron deficiency anemia, persistent vomiting, palpable abdominal mass, adenopathy, or abdominal imaging suggesting organic disease
    • dyspepsia at any age in patient with family history of upper GI malignancy in first-degree relative
    • childhood spent in regions with elevated risk of GI malignancy (such as Southeast Asia or part of South America)
    • male sex (age-adjusted gastric cancer rate of men is twice that of women)
  • Initial Helicobacter pylori infection test-and-treat strategy before endoscopy may be appropriate in patients without any of the above features who are considered to have a low risk of GI malignancy:
• Test for H. pylori infection in patients presenting with suspected or known peptic ulcer disease.
  • For patients without an indication for endoscopy, offer noninvasive test for H. pylori infection, such as urea breath test or fecal antigen test.
  • For patients having endoscopy who have not had previous noninvasive testing for H. pylori infection, collect gastric biopsies at time of endoscopy.
  • In patients negative for H. pylori infection and without an indication for endoscopy, consider empiric proton pump inhibitor therapy.
  • In patients negative for H. pylori and with no response to empiric PPI therapy, consider endoscopy.
• Consider biopsy for gastric ulcers seen on endoscopy (Weak recommendation), but do not routinely biopsy duodenal ulcers due to low likelihood of malignancy (Strong recommendation).

Management

• For patients on chronic nonsteroidal anti-inflammatory drugs (NSAIDs), consider primary ulcer prophylaxis with proton pump inhibitor (PPI) if there are risk factors for peptic ulcer disease, such as age > 50 years and concomitant use of aspirin, anticoagulants, or corticosteroids.
• See Acute nonvariceal upper gastrointestinal bleeding for management of acutely bleeding ulcers.
• For uncomplicated peptic ulcer in patients taking NSAIDs:
  • Prescribe PPI to promote ulcer healing (for 4-6 weeks for duodenal and 6-8 weeks for gastric ulcers).
  • Stop NSAID or aspirin use if possible or limit dosage. However, patients with high cardiovascular risk may need to continue aspirin therapy with concomitant PPI.
  • For patients continuing to take NSAIDs following ulcer healing:
    • Use gastric protection with PPI (Strong recommendation).
    • Consider substituting a cyclooxygenase-2 (COX-2) NSAID using the lowest effective dose (Weak recommendation). All NSAIDs may increase risk for renal and cardiovascular disease.
    • Periodically reassess need for NSAID (Strong recommendation).
• For H. pylori-positive ulcers:
  • Provide H. pylori eradication therapy (Strong recommendation).
  • Test to confirm H. pylori eradication (using urea breath test, fecal antigen test, or biopsy-based testing) ≥ 4 weeks after completion of antibiotic therapy and after PPIs have been withheld for 1-2 weeks (Strong recommendation).
• Treat idiopathic peptic ulcers (unrelated to either H. pylori infection or NSAID use) with PPI (typically 6-8 weeks).
• Consider maintenance PPI therapy at lowest appropriate dose after ulcer healing in patients at high risk for recurrence or complications, such as those continuing to take NSAIDs or aspirin.
• Consider surgery in selected patients unable to be treated medically or those with complications. Surgery is indicated for patients with gastric outlet obstruction, perforation penetration, or uncontrolled bleeding.