Approach to uncomplicated Peptic Ulcer Disease

June 29, 2022

Q. What is Uncomplicated Peptic Ulcer Disease?
Peptic ulcers are ulcers that affect the stomach and small intestines. Basically, the thick protective mucus layer is reduced, resulting with the acidic digestive juices damaging the layer and causing an ulcer. An uncomplicated peptic ulcer refers to an ulcer that does not present perforation or deep damage.

Q. What are the risk factors of a Peptic Ulcer?
The two most important risk factors for developing peptic ulcer disease are non-steroidal anti-inflammatory drugs (NSAIDS) abuse and Helicobacter pylori infection. Smoking and alcohol intake are also some of the risk factors for P.U.D that must be solicited from history.

Q. What are the Symptoms of a Peptic Ulcers?
It is important to remember that these patients might present complaining of heartburn, associated with abdominal pains in the epigastric area, these symptoms might be provoked by eating.

The clinical assessment of P.U.D entails the check on the C.A.J.C.O.L.D with the emphasis on presence or absence of jaundice. C – Cyanoses (will be cyanosed); A – Anemia (headache, insomnia, shortness of breath, fatigue, dizziness, difficulty concentrating and pale skin); J – Jaundice (yellow discolouration of the eye); C – Clubbing (distorted angle of nail bed of the fingers); O – Oedema (subcutaneous putting edema); L – Lymphadenopathy.

Inflammation of the lymph nodes) and D – Dehydration (thirst dry skin, dry mouth, less urination and rapid heartbeat). The Abdominal exam for uncomplicated Peptic Ulcer Disease (P.U.D) one might find mild tenderness in the epigastric area. lymph nodes) and D – Dehydration (thirst dry skin, dry mouth, less urination and rapid heartbeat). The Abdominal exam for uncomplicated Peptic Ulcer Disease (P.U.D) one might find mild tenderness in the epigastric area.

Q. What are the special investigations performed to diagnose Peptic Ulcer Disease?
Full blood count: to check Hb and mean corpuscular volume, might have anemia of chronic disorders due to chronic blood loss from ulcers. Kidney function to check electrolytes. Tests that are specific for H pylori are Urea breath test and direct culture for H-pylori from the gastric biopsy.

Endoscopy – gastroduodenoscopy is one of the first line investigations that one does to confirm a diagnosis of peptic ulcers.

Q. What are the treatment methods?
Medical Treatments: Withdrawing from contributing towards the risk factors such as smoking, regular intake of alcohol, consumption of spicy food and untreated stress, amongst others.

Eradication of H-pylori: first line therapy is PPI (omeprazole or lansoprazole), Amoxil 1g per os bd and clarithromycin 500mg per os bd, if the patient is allergic to penicillin, then you can replace Amoxil with metronidazole. Antibiotics along with PPI are given for a period of 10-14 days to reduce chances of H-pylori re-infection.

Second line treatment: PPI, bismuth subcitrate 120mg per os qid, tetracycline 500mg per os qid and metronidazole 400mg per so tds.

Antisecretory therapy (PPI): H pylori positive uncomplicated duodenal ulcers, PPI is given for 14 days along with antibiotic regimen to eradicate H-pylori, long term PPI is not necessary if they remain asymptomatic. H-pylori positive complicated duodenal ulcers it is recommended to continue PPI for 8 to 12 weeks. H-pylori positive gastric ulcers PPI can only be discontinued after 12 weeks when ulcer healing is confirmed on G- scope.

NSAID induced ulcer: these patients should be treated with PPI for a minimum period of 8 weeks. In patients who need to remain on NSAID maintenance therapy with PPI should be considered to reduce the risk of ulcer complications.

Non NSAIDS and Non-H pylori induced ulcers: these patients must be on lifelong PPI.

Surgical Treatments: Indication for surgical intervention: Bleeding peptic ulcer; Perforated peptic ulcer; Gastric outlet obstruction; Suspected malignancy and Intractable disease.

Surgical approaches that reduce acid secretion:
Sectioning of the vagus nerve (truncal vagotomy, highly selective vagotomy), truncal vagotomy usually result in delayed gastric emptying and so one will need to do a drainage procedure along with it.

Eliminating the hormonal stimulation from the antrum (Antrectomy).

Decreasing the number of acids producing cells (Subtotal gastrectomy).

A combination of any of the above procedures (e.g., vagotomy plus antrectomy).

Drainage procedures: Heineke Mikulicz pyloroplasty; Finney pyloroplasty and Jaboulay pyloroplasty.

Gastrectomy and reconstruction:
Partial gastrectomy (antrectomy, subtotal gastrectomy) removes the portion of the stomach containing ulcer, gastrin producing cells that stimulate acid secretion and a variable number of acids producing parietal cells. Antrectomy would not remove any parietal cells, while subtotal gastrectomy would remove some but not all parietal cells. Reconstruction of the gastrointestinal tract can be done via Billroth 1 procedure, or Billroth 2 procedure, or Roux and Y procedure. Billroth 1 procedure may be difficult to accomplish due to severe inflammation in the region around the pylorus and the duodenum and therefore it’s not advisable.

Dr Lucky Khambule
Dr Lucky Khambule

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