PEPTIC ULCER DISEASE

Ulceration of gastro-duodenal mucosa. It tends to be chronic and recurrent if untreated.

Causes

  • Helicobacter pylori infection

Hyperacidity due to

  • Drugs (NSAIDS e.g. acetylsalicylic acid, corticosteroids)
  • Irregular meals
  • Stress
  • Alcohol and smoking
  • Caffeine-containing beverages

Clinical features

General

  • Epigastric pain typically worse at night and when hungry (duodenal ulcer) alleviated by food, milk, or antacid
    medication
  • Epigastric pain, worse with food (gastric ulcer)
  • Vomiting, nausea, regurgitation
  • Discomfort on palpation of the upper abdomen

Bleeding ulcer

  • Haematemesis (coffee brown or red vomitus)
  • Black stools (i.e. melena)
  • Sudden weakness and dizziness
  • Cold, clammy skin (when patient has lost a lot of blood)

Perforated ulcer

  • Acute abdominal pain, signs of peritonitis such as rigid abdomen
  • Ground coffee-brown vomitus (due to blood)
  • Fever
  • Shock (weak pulse, clammy skin, low blood pressure)

Differential diagnosis

  • Pancreatitis, hepatitis
  • Disease of aorta, myocardial infarction
  • Lung disease (haemoptysis)

Investigations

  • Positive stool antigen for H. pylori. Used for diagnosis and to confirm eradication.
    • This test may give false negative if the patient has been taking antibiotics or omeprazole in the previous 2 weeks
  • Gastroscopy
  • Biopsy of stomach wall
  • Barium meal

SERUM ANTIBODY TEST IS NOT USEFUL FOR DIAGNOSIS AND FOLLOW UP

Management and Prevention

  • Modify diet: avoid precipitating causes and increase milk intake
  • Give an antacid
    • Magnesium trisilicate compound 2 tablets every 8 hours as required

Treatment for eradication of H. pylori (Triple therapy)

Combination 1 (First line)

  • Amoxycillin 1 g every 12 hours PLUS metronidazole 400 mg every 12 hours PLUS omeprazole 20 mg every 12 hours for two weeks
    • Check eradication with a stool antigen test after 4 weeks

For bleeding and perforated ulcer

  • Refer patient to hospital immediately for
    • IV fluids and blood if necessary
    • IV ranitidine 50 mg in 20 ml slowly every 8 hours
Note
  • Tinidazole 500 mg every 12 hours can be used instead of metronidazole
  • Confirm eradication with stool antigen test a month after completion of treatment; test should be negative