Detection of antibodies in serum (inexpensive, preferred when endoscopy is not required); rapid urease test of antral biopsy (when endoscopy is required). Urea breath test generally used to confirm eradication of H. pylori, if necessary. The fecal antigen test is sensitive, specific, and inexpensive (Table 147-1).
Treatment: Peptic Ulcer Disease MEDICAL: Objectives: pain relief, healing, prevention of complications, prevention of recurrences. For GU, exclude malignancy (follow endoscopically to healing). Dietary restriction unnecessary with contemporary drugs; discontinue NSAIDs; smoking may prevent healing and should be stopped. Eradication of H. pylori markedly reduces rate of ulcer relapse and is indicated for all DUs and GUs associated with H. pylori (Table 147-2). Acid suppression is generally included in regimen. Reinfection rates are <1%/year. Standard drugs (H2 receptor blockers, sucralfate, antacids) heal 80-90% of DUs and 60% of GUs in 6 weeks; healing is more rapid with omeprazole (20 mg/d). SURGERY: Used for complications (persistent or recurrent bleeding, obstruction, perforation) or, uncommonly, intractability (first screen for surreptitious NSAID use and gastrinoma). For DU, see Table 147-3. For GU, perform subtotal gastrectomy. COMPLICATIONS OF SURGERY: (1) Obstructed afferent loop (Billroth II), (2) bile reflux gastritis, (3) dumping syndrome (rapid gastric emptying with abdominal distress + postprandial vasomotor symptoms), (4) postvagotomy diarrhea, (5) bezoar, (6) anemia (iron, B12, folate malabsorption), (7) malabsorption (poor mixing of gastric contents, pancreatic juices, bile; bacterial overgrowth), (8) osteomalacia and osteoporosis (vitamin D and Ca malabsorption), (9) gastric remnant carcinoma. |
Approach to the Patient: Peptic Ulcer Disease Optimal approach is uncertain. Serologic testing for H. pylori and treating, if present, may be cost-effective. Other options include trial of acid-suppressive therapy, endoscopy only in treatment failures, or initial endoscopy in all cases. |