Author:

Yanina A.Purim-Shem-Tov

Signs and Symptoms

• Epigastric pain or tenderness (80-90%):
  • Burning, gnawing, aching pain
  • Location: Midline, xiphoid, or umbilicus
• Duodenal ulcers:
  • Pain occurs 90 min-3 hr after meals
  • Usually awakens patient at night
  • Food and antacids relieve pain
• Gastric ulcers:
  • Pain worsens after meals
  • Nausea and anorexia
• Difficult to differentiate clinically between gastric and duodenal ulcers
• Relief of pain with antacids
• Heme-positive stools
• Complications of peptic ulcer disease (PUD):
  • Acute perforation:
    • Rigid, boardlike abdomen
    • Generalized rebound tenderness
    • Pain radiation to back or shoulder
  • Obstruction:
    • Pain with vomiting
    • Succussion splash from retained gastric contents and abdominal distention
  • Hemorrhage:
    • Hematemesis
    • Melena
    • Hypotension
    • Tachycardia
    • Skin pallor
    • Orthostatic changes

Essential Workup

• Careful physical exam including hemoccult testing and vital signs with orthostatics
• For stable patients, oral GI cocktail typically relieves pain:
  • Antacid: 30 mL
  • Viscous lidocaine: 10 mL

Diagnostic Tests & Interpretation

Differential Diagnosis

• Gastroesophageal reflux
• Biliary colic
• Cholecystitis
• Pancreatitis
• Gastritis
• Abdominal aortic aneurysm
• Aortic dissection
• Myocardial infarction
• Subset with symptoms and no ulcer on endoscopy called nonulcer dyspepsia

Prehospital

• ABCs
• IV fluid resuscitation for hypotensive/shock patients

Initial Stabilization/Therapy

• ABCs
• Identify ulcer complications (hemorrhage, perforation, obstruction)
• Treat hypotension with lactated Ringer/normal saline fluid bolus via 2 large-bore IVs
• Type and cross early
• Nasogastric tube (NGT) for gastric decompression/check for hemorrhage

ED Treatment/Procedures

• Pain control with antacids (GI cocktail) or IV H₂ antagonists
• Avoid narcotics - may mask serious illness
• Promotion of ulcer healing:
  • Antacids
  • H₂ antagonists (cimetidine, famotidine, ranitidine, nizatidine):
    • May continue for 2-5 yr for ulcer suppression therapy
  • Proton-pump inhibitors preferred in NSAID induced ulcers (PPIs; omeprazole, lansoprazole, or pantoprazole):
    • If H₂ antagonists have failed
  • Sucralfate
  • Prostagland in congeners (misoprostol)
  • Sucralfate, H₂-receptor antagonists, and PPIs should not be combined because of lack of documented benefit
• Gastric outlet obstruction:
  • Decompress stomach with NGT
  • IV hydration
• Gastric hemorrhage:
  • IV fluid resuscitation
  • Blood transfusion depending on loss/hematocrit
  • Foley catheter to monitor volume status
  • GI consultation
• Perforation:
  • IV hydration
  • Foley catheter to monitor hydration status
  • Preoperative antibiotics
  • Emergency surgical consultation
• Treatment of H. pylori infection:
  • Invasive or noninvasive testing to confirm infection
  • Clarithromycin triple therapy:
    • 14-d therapy
    • PPI twice daily
    • Clarithromycin (500 mg) twice daily
    • Amoxicillin (1 g) twice daily or metronidazole (500 mg) 3× daily
  • Sequential 10-d therapy in high prevalence areas:
    • Double therapy for 5 d:
      • PPI
      • Amoxicillin (1 g)
    • Followed by triple therapy for 5 d:
      • PPI
      • Clarithromycin (500 mg)
      • Metronidazole (500 mg)
  • Bismuth-based quadruple therapies:
    • PPI (stand ard dose)
    • Bismuth subcitrate (120-300 mg, or 420 mg) or bismuth subsalicylate (300 or 524 mg) 4× daily
    • Tetracycline (500 mg) 4× daily
    • Metronidazole (500 mg) 3× daily
  • Concomitant therapy 10/14 d:
    • PPI twice daily
    • Clarithromycin (500 mg) and amoxicillin (1 g) or metronidazole (500 mg) given twice daily
  • Hybrid therapy:
    • PPI twice daily plus amoxicillin (1 g) twice daily for 5 d, followed by
    • PPI, clarithromycin (500 mg), amoxicillin (500 mg), plus metronidazole (500 mg) or tinidazole (500 mg) given twice daily for 7 d
  • Levofloxacin sequential therapy:
    • PPI twice daily plus amoxicillin (1 g) twice daily for 5-7 d, followed by
    • PPI, levofloxacin (500 mg) once daily, amoxicillin (500 mg) twice daily, plus metronidazole or tinidazole (500 mg) given twice daily for 5-7 d
• Stop NSAIDs
• Surgical therapy:
  • Refractory ulcer
  • Complications:
    • Bleeding
    • Perforation
    • Pyloric stenosis

Medication

• Bismuth subsalicylate: 2 525 mg tabs PO
• Maalox Plus: 2-4 tabs PO q.i.d
• Misoprostol: 100-200 mcg PO q.i.d
• Mylanta II: 2-4 tabs PO q.i.d
• Sucralfate: 1 g PO q.i.d for 6-8 wk
• Famotidine (H₂ blocker): 40 mg PO nightly at bedtime (peds: 0.5-0.6 mg/kg q12h) for 6-8 wk
• Nizatidine (H₂ blocker): 300 mg PO nightly at bedtime for 6-8 wk; 20 mg PO b.i.d (peds: 5-10 mg/kg/24 hr divided b.i.d) for 2 wk
• Ranitidine (H₂ blocker): 300 mg PO nightly at bedtime (peds: 5-10 mg/kg/24 hr given q12h) for 6-8 wk
• Cimetidine (H₂ blocker): 400 mg PO b.i.d for 6-8 wk
• Lansoprazole (PPI): 30 mg PO b.i.d for 2 wk
• Pantoprazole (PPI): 40 mg PO daily for 2 wk
• Omeprazole (PPI): 20 mg PO b.i.d for 2 wk
• Rabeprazole (PPI): 20 mg PO daily for 6 wk
• Esomeprazole (PPI): 40 mg daily for 4 wk
• H. pylori therapy:
  • Multiple options above

Disposition

Follow-up Recommendations

• High-risk patients include those with the following characteristics:
  • Bleeding with hemodynamic instability
  • Repeated hematemesis or any hematochezia
  • Failure to clear with gastric lavage
  • Coagulopathy
  • Comorbid disease
  • Advanced age
  • Patients with ulcer perforation or penetration require operative repair
• All patients require primary care follow-up in 2-6 wk to evaluate efficacy of treatment
• Patients >55 yr and patients with severe symptoms should receive GI referral for endoscopy and testing for H. pylori

• BarkunA, LeontiadisG. Systematic review of the symptom burden, quality of life impairment and costs associated with peptic ulcer disease . Am J Med. 2010;123:358-366.
• CheyWD, WongBC; Practice Parameters Committee of the American College of Gastroenterology. American College of Gastroenterology guideline on the management of Helicobacter pylori infection . Am J Gastroenterol. 2007;102(8):1808-1825.
• LanasA, ChanFKL. Peptic ulcer disease . Lancet. 2017;390(10094):613-624.
• LanzaFL, ChanFK, QuigleyEM. Guidelines for prevention of NSAID-related ulcer complications . Am J Gastroenterol. 2009;104(3):728-738.
• MalfertheinerP, ChanFK, McCollKE. Peptic ulcer disease . Lancet. 2009;374:1449-1461.

See Also (Topic, Algorithm, Electronic Media Element)

• Gastroesophageal Reflux Disease
• Gastritis
• Gastrointestinal Bleeding

ICD9

• 531.30 Acute gastric ulcer without mention of hemorrhage or perforation, without mention of obstruction

• 532.30 Acute duodenal ulcer without mention of hemorrhage or perforation, without mention of obstruction

• 533.90 Peptic ulcer of unspecified site, unspecified as acute or chronic, without mention of hemorrhage or perforation, without mention of obstruction

• 532.10 Acute duodenal ulcer with perforation, without mention of obstruction

• 531.00 Acute gastric ulcer with hemorrhage, without mention of obstruction

• 531.01 Acute gastric ulcer with hemorrhage, with obstruction

• 531.0 Acute gastric ulcer with hemorrhage

• 531.10 Acute gastric ulcer with perforation, without mention of obstruction

• 531.11 Acute gastric ulcer with perforation, with obstruction

• 531.1 Acute gastric ulcer with perforation

• 531.20 Acute gastric ulcer with hemorrhage and perforation, without mention of obstruction

• 531.21 Acute gastric ulcer with hemorrhage and perforation, with obstruction

• 531.2 Acute gastric ulcer with hemorrhage and perforation

• 532.00 Acute duodenal ulcer with hemorrhage, without mention of obstruction

• 532.01 Acute duodenal ulcer with hemorrhage, with obstruction

• 532.0 Acute duodenal ulcer with hemorrhage

• 532.11 Acute duodenal ulcer with perforation, with obstruction

• 532.1 Acute duodenal ulcer with perforation

• 532.20 Acute duodenal ulcer with hemorrhage and perforation, without mention of obstruction

• 532.21 Acute duodenal ulcer with hemorrhage and perforation, with obstruction

• 532.2 Acute duodenal ulcer with hemorrhage and perforation

• 532.31 Acute duodenal ulcer without mention of hemorrhage or perforation, with obstruction

• 532.3 Acute duodenal ulcer without mention of hemorrhage or perforation

• 533.00 Acute peptic ulcer of unspecified site with hemorrhage, without mention of obstruction

• 533.10 Acute peptic ulcer of unspecified site with perforation, without mention of obstruction

• 533.20 Acute peptic ulcer of unspecified site with hemorrhage and perforation, without mention of obstruction

• 533.21 Acute peptic ulcer of unspecified site with hemorrhage and perforation, with obstruction

• 533.2 Acute peptic ulcer of unspecified site with hemorrhage and perforation

ICD10

• K25.3 Acute gastric ulcer without hemorrhage or perforation

• K26.3 Acute duodenal ulcer without hemorrhage or perforation

• K27.9 Peptic ulc, site unsp, unsp as ac or chr, w/o hemor or perf

• K26.1 Acute duodenal ulcer with perforation

• K25.0 Acute gastric ulcer with hemorrhage

• K25.1 Acute gastric ulcer with perforation

• K25.2 Acute gastric ulcer with both hemorrhage and perforation

• K26.0 Acute duodenal ulcer with hemorrhage

• K26.2 Acute duodenal ulcer with both hemorrhage and perforation

SNOMED

• 13200003 Peptic ulcer (disorder)

• 235687004 Acute peptic ulcer of duodenum

• 235647009 Acute peptic ulcer of stomach

• 79118000 Acute peptic ulcer with perforation (disorder)

• 196687006 Acute peptic ulcer with obstruction (disorder)

• 64121000 peptic ulcer with hemorrhage (disorder)