Peptic Ulcer Disease 

-     Chronic illness, recurrent ulcers in stomach and duodenum 

-     Commonly due to H. Pylori (more on this next week!) and NSAIDs 

-     Protective factors: prostaglandin, mucus, and bicarb production 

-     10% people in the western world will have this in their lifetime 

-     Sx: burning, gnawing, achy, “empty, hungry” epigastric pain 

-     Relieved by ingestion of food (usually), milk, antacids (buffers/dilutes gastric acid) 

-     Worsens after gastric emptying, classically the pain awakens patients at night

-     Chronic ulcers can be asymptomatic or cause painless GI bleeding

-     NOT (usually) related to PUD: pain after eating, nausea, belching 

-    “Alarm features” for suspicion of cancer –> need more emergent endoscopy: >50 yo, weight loss, persistent vomiting, dysphagia/odynophagia, GIB, abdominal mass, lymphadenopathy, Family hx

-      Exam: for uncomplicated PUD, expect benign physical exam +/-epigastric tenderness (not sensitive or specific). VS should be normal. 

-     Workup:

            -     Generally includes CBC to rule out anemia from chronic GIB

            -     Consider LFT, lipase, EKG, trop, upright CXR, RUQ US to rule out other etiologist that may present similarly with epigastric pain if indicated

-     Gold standard for Diagnosis: endoscopy 

-     Treatment: 

-     Stop NSAIDs 

-     Proton pump inhibitors, H2 receptor antagonists, sucralfate, and antacids 

-    PPI: decrease acid secretion from gastric parietal cells, irreversibly bind with H+K+ATPase (proton pump). Example: omeprazole, pantoprazole. Heal ulcers faster than any other tx. 

-    H2 receptor antagonists: Inhibit action of histamine on H2 receptor on gastric parietal cells (example: famotidine, ranitidine). Dose should be adjusted for patients in renal failure. 

-    Sucralfate: covers ulcer crater, protects it and allows healing, but doesn’t relieve pain as well 

-    Antacids: buffer gastric acid. Use for breakthrough pain. (Ex: Mylanta, Rolaids, Tums, etc) 

-     Dispo: as long as uncomplicated (no bleed, obstruction, perforation, etc) can be discharged from ED with Rx for meds above and referral to PCP or GI 

Gastritis

-     Not the same as PUD

-     Acute or chronic inflammation of gastric mucosa (not discrete ulcers) 

-     Causes: ischemia, toxic effects of NSAIDs, steroids, bile, alcohol, H. Pylori, autoimmune processes that destroy gastric parietal cells 

-     Exam: epigastric pain, N/V. Often presents with GIB: hematemesis vs chronic anemia vs melena 

References:

1.     Fashner J, Gitu AC. Diagnosis and Treatment of Peptic Ulcer Disease and H. pylori Infection. Am Fam Physician. 2015 Feb 15;91(4):236-42. PMID: 25955624.

2.     Malfertheiner P, Chan FK, McColl KE. Peptic ulcer disease. Lancet. 2009 Oct 24;374(9699):1449-61. doi: 10.1016/S0140-6736(09)60938-7. Epub 2009 Aug 13. PMID: 19683340.