Surgery Gastrointestinal Surgery

Peptic ulcer disease (PUD) / Helicobacter pylori

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18 أقسام

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Background

  • Peptic ulcer disease (PUD) is an erosion or defect in the mucosal lining of the stomach, duodenum, and sometimes the lower oesophagus (due to imbalance between the mucosal protective factors and gastric acid secretions)
  • The leading cause is helicobacter pylori followed by nonsteroidal anti-inflammatory drugs (NSAIDs) use
  • Risk factors include NSAIDs, smoking, stress and age (ulcer incidence increases with age)
  • Associated conditions include: Zollinger-Ellison syndrome (suspect in patients with refractory duodenal ulcers), Behçet’s disease, and Crohn’s disease
Gastric ulcer Duodenal ulcer
Pain
  • Increases with meals (weight loss)
  • Decreases with meals (weight gain)
H. Pylori infection
  • 70%
  • 90%
Mechanism
  • Decrease mucosal protection against gastric acid
  • Decrease mucosal protection against gastric acid or increase gastric acid secretion
Other causes
  • NSAIDs
  • Zollinger-Ellison syndrome
Risk of carcinoma
  • Increases risk of gastric carcinoma (biopsy must be performed to rule out malignancy)
  • Generally benign
  • Not routinely biopsied

 

Helicobacter pylori infection
Clinical presentation
  • Asymptomatic (85%)
  • Dyspepsia
  • Cancer (MALToma): proliferation of B cells and T cells in gastric lamina
Diagnosis
  • Urease breath test (initial diagnosis)
  • Stool antigen test (good for eradication)
  • Endoscopy and biopsy (gold standard)
  • Serum gastrin (to evaluate for Zollinger-Ellison syndrome)
Treatment
  • Triple therapy (PPI, clarithromycin, and amoxicillin)
  • In case of penicillin allergy, metronidazole should be used (avoid alcohol consumption when on metronidazole)

 

 

Version 2

Definition

  • Peptic ulcer disease (PUD): Erosion or defect in the mucosal lining of the stomach, duodenum, and sometimes lower esophagus that extends through the muscularis mucosae (≥0.5 cm diameter)

Epidemiology

  • ★ Prevalence: 5-10% lifetime risk in general population
  • ★ Most common age:
    • Duodenal ulcers: 30-55 years
    • Gastric ulcers: 55-70 years
  • ★ Gender:
    • Duodenal ulcers: Male > Female (4:1)
    • Gastric ulcers: Male = Female
  • ★ Most common location: First part of duodenum (duodenal bulb)

Risk Factors

  • Major risk factors:
    • ★ H. pylori infection (most important)
    • ★ NSAIDs (including low-dose aspirin)
    • Smoking (impairs healing)
    • Advanced age (>60 years)
    • Previous PUD history
  • Associated conditions:
    • ★ Zollinger-Ellison syndrome (gastrinoma) - suspect with refractory/multiple ulcers
    • Behçet's disease
    • Crohn's disease
    • Systemic mastocytosis

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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Types/Classification

Feature Gastric Ulcer Duodenal Ulcer ★
Frequency 25% of PUD ★ 75% of PUD (most common)
Pain timing
  • ★ Worsens with meals
  • 30-60 minutes postprandial
  • → Weight loss (food avoidance)
  • ★ Improves with meals
  • 2-3 hours postprandial
  • ★ Nocturnal pain (11 PM - 2 AM)
  • → Weight gain
H. pylori association 70% ★ 90%
Pathophysiology ↓ Mucosal protection ↓ Mucosal protection OR ↑ Acid secretion
Other causes ★ NSAIDs (most common after H. pylori) Zollinger-Ellison syndrome
Malignancy risk
  • ★ 3-5% are malignant
  • ⚠️ Always biopsy
  • ★ <0.5% malignancy risk
  • Biopsy not routine
Most common location ★ Lesser curvature of antrum ★ First part of duodenum (within 3 cm of pylorus)
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Helicobacter pylori

Helicobacter pylori Infection
Microbiology
  • ★ Gram-negative, spiral-shaped, flagellated bacterium
  • ★ Urease-positive (produces ammonia → ↑ pH)
  • Microaerophilic
Virulence factors
  • ★ Urease: NH₃ production → neutralizes gastric acid
  • CagA toxin: → gastric adenocarcinoma risk
  • VacA toxin: → epithelial damage
  • Flagella: → motility in mucus layer
Clinical presentation
  • ★ Asymptomatic: 85%
  • Dyspepsia: 10-15%
  • PUD: 10-15%
  • Gastric cancer: 1-3%
  • ★ MALT lymphoma: <1%
Diagnosis
  • ★ Best initial test: Urea breath test or stool antigen
  • ★ Most accurate: EGD with biopsy + rapid urease test
  • Serology: Not for active infection (remains positive after treatment)
  • ⚠️ Stop PPI 2 weeks before testing
Treatment
  • ★ First-line triple therapy (14 days):
    • PPI (omeprazole 20mg BID)
    • Clarithromycin 500mg BID
    • Amoxicillin 1g BID
  • Penicillin allergy: Replace amoxicillin with metronidazole 500mg BID
  • ★ Confirm eradication: Urea breath test 4 weeks after completion
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Clinical presentations

  • Symptoms
    • Asymptomatic (20%)
    • Gnawing epigastric pain (most commonly at the upper quadrants)
    • Nocturnal pain (due to circadian rhythm of gastric acid secretion)
    • Hematemesis and Melina
    • Perforated viscus (severe pain, guarding, rigidity, reduced bowel sounds, and signs of shock)
  • Physical examination
    • Abdominal tenderness
    • Peritoneal signs if perforation
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Clinical Presentations - Version 2

 

Classic Presentations by Demographics

 

  • ★ Young male (30-40 years) with epigastric pain relieved by food: Duodenal ulcer
  • ★ Elderly patient (>60 years) with epigastric pain worsened by food + weight loss: Gastric ulcer (rule out malignancy)
  • ★ Patient with multiple ulcers in unusual locations: Zollinger-Ellison syndrome
  • ★ Patient on chronic NSAIDs with iron deficiency anemia: NSAID-induced ulcer with chronic bleeding

 

Symptoms

 

  • Most common symptom: ★ Epigastric burning/gnawing pain (70-80%)
  • Asymptomatic: 20% (especially elderly on NSAIDs)
  • Other symptoms:
    • Nausea/vomiting
    • Bloating, belching
    • Early satiety (gastric ulcer)
    • ★ Nocturnal awakening (duodenal ulcer)
  • Alarm symptoms (require immediate EGD):
    • ★ Age >55 with new-onset dyspepsia
    • ★ Unintentional weight loss
    • ★ Progressive dysphagia
    • ★ Persistent vomiting
    • ★ GI bleeding (hematemesis, melena)
    • ★ Iron deficiency anemia
    • Family history of gastric cancer

 

Physical Examination

 

  • Uncomplicated PUD:
    • Epigastric tenderness
    • Otherwise normal exam
  • Complicated PUD:
    • Perforation: ★ Rigid abdomen, rebound tenderness, absent bowel sounds
    • Bleeding: Tachycardia, hypotension, melena/hematemesis
    • Obstruction: Succussion splash, visible peristalsis

 

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Diagnosis

  • Esophageogastroduodenoscopy (EGD) is the gold standard
  • Biopsy (to differentiate between benign ulcers and malignancy)
  • Abdominal and chest X-rays (to detect pneumoperitoneum secondary to perforation)
  • Rule out malignancy
  • Rule out helicobacter pylori
EGD Findings Probable cause
Shallow and multiple NSAIDs
Big and heaped up margins Malignancy
Single ulcer Helicobacter pylori
Multiple ulcer in intestines Gastrinoma

 

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Diagnosis - Version 2

 

Diagnostic Algorithm

 

★ HIGH-YIELD DIAGNOSTIC APPROACH:

  1. Age <55 without alarm symptoms: Test and treat for H. pylori
  2. Age ≥55 OR alarm symptoms: Proceed directly to EGD
  3. Failed empiric therapy: EGD with biopsy

 

Diagnostic Tests

 

  • ★ Gold standard: EGD with biopsy
    • Direct visualization
    • Biopsy for H. pylori and malignancy
    • Therapeutic intervention if bleeding
  • H. pylori testing:
    • Non-invasive:
      • ★ Urea breath test (95% sensitive/specific)
      • ★ Stool antigen test (>90% sensitive/specific)
      • Serology (not for active infection)
    • Invasive (during EGD):
      • ★ Rapid urease test (CLOtest)
      • Histology
      • Culture (for antibiotic resistance)
  • Other tests:
    • Serum gastrin: If Zollinger-Ellison suspected (>1000 pg/mL)
    • CXR/CT: Free air under diaphragm if perforation

 

EGD Findings

 

EGD Finding Probable Cause Action
Multiple shallow ulcers ★ NSAIDs Stop NSAIDs, PPI therapy
Large ulcer with heaped margins ★ Malignancy Multiple biopsies (6-8)
Single deep ulcer H. pylori Biopsy, triple therapy
Multiple ulcers in jejunum ★ Zollinger-Ellison syndrome Check serum gastrin, CT/MRI for gastrinoma

 

Forrest Classification (Upper GI Hemorrhage)

 

Stage Description Rebleeding Risk Management
Ia ★ Spurting arterial hemorrhage 90% Urgent endoscopic therapy
Ib Oozing hemorrhage 50% Endoscopic therapy
IIa ★ Visible vessel (non-bleeding) 40-50% Endoscopic therapy
IIb Adherent clot 20-30% Consider endoscopic therapy
IIc Flat pigmented spot (hematin) 10% Medical therapy only
III ★ Clean base <5% Medical therapy only
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Differential diagnosis

  • Gastric malignancy (confirmed by biopsy)
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Differential Diagnosis - v2

Condition Key Distinguishing Features Test to Differentiate Classic Patient
GERD
  • ★ Substernal burning
  • Worse when supine
  • Regurgitation
 24-hour pH monitoring Obese patient with heartburn after large meals
Gastric cancer
  • ★ Weight loss
  • ★ Early satiety
  • Virchow's node
 EGD with biopsy Elderly Asian male with new dyspepsia
Chronic pancreatitis
  • ★ Pain radiates to back
  • Steatorrhea
  • Diabetes
 CT scan, fecal elastase Alcoholic with recurrent epigastric pain
Biliary colic
  • ★ RUQ pain
  • Postprandial (fatty foods)
  • Lasts 30 min - 6 hours
 RUQ ultrasound Obese female with RUQ pain after fatty meal
Functional dyspepsia
  • Normal EGD
  • ★ Rome IV criteria
  • No alarm symptoms
 Diagnosis of exclusion Young woman with chronic symptoms, normal workup
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Treatment

  • Conservative management
    • Smoking and alcohol cessation
    • Stop NSAIDs
    • Proton pump inhibitor
    • Triple therapy for helicobacter pylori

      Algorithm for treatment following biopsy
      A biopsy shows signs of NSAIDs use
      • Stop NSAIDs
      A biopsy shows cancer
      • Stage and treat accordingly
      A biopsy shows H. Pylori
      • Triple therapy

       

  • Surgical management
    • Selective vagotomy
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Treatment - v2

 

Medical Management

 

★ FIRST-LINE TREATMENT ALGORITHMS:
1. H. pylori-positive PUD:
  • Triple therapy (14 days):
    • PPI (omeprazole 20mg BID or equivalent)
    • Clarithromycin 500mg BID
    • Amoxicillin 1g BID (or metronidazole 500mg BID if PCN allergy)
  • Quadruple therapy (if clarithromycin resistance >15%):
    • PPI BID
    • Bismuth subsalicylate 525mg QID
    • Metronidazole 250mg QID
    • Tetracycline 500mg QID

2. NSAID-induced PUD:

  • ★ Discontinue NSAIDs (most important)
  • PPI therapy for 8 weeks
  • If NSAID must continue: PPI prophylaxis indefinitely

3. H. pylori-negative, NSAID-negative PUD:

  • PPI therapy for 4-8 weeks
  • Investigate for rare causes (Zollinger-Ellison, Crohn's)

 

PPI Dosing (Equivalents)

 

  • Omeprazole: 20-40mg daily
  • Esomeprazole: 20-40mg daily
  • Lansoprazole: 15-30mg daily
  • Pantoprazole: 40mg daily
  • Rabeprazole: 20mg daily

 

Surgical Management

Indications (rare in PPI era):

 

  • ★ Perforation
  • Uncontrolled bleeding despite endoscopic therapy
  • Gastric outlet obstruction
  • Refractory ulcers (rule out malignancy)

Procedures:

  • Perforation: Graham patch (omental patch)
  • Bleeding: Oversewing of vessel ± vagotomy
  • Obstruction: Gastrojejunostomy or pyloroplasty
  • Refractory: Selective vagotomy + drainage
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Complications

Ulcer complications
Haemorrhage
  • Gastric, duodenal (posterior > anterior)
  • Most common complication
  • Ruptured lesser curvature (bleeding from left gastric artery)
  • Rupture of posterior wall of duodenum (bleeding from gastroduodenal artery)
Obstruction
  • Pyloric channel, duodenal
Perforation
  • Duodenal (anterior > posterior)
  • Anterior duodenal ulcers can perforate into the anterior abdominal cavity
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Complications - v2

⚠️ COMPLICATIONS OF PUD
Hemorrhage (15%)
  • ★ Most common complication
  • Gastric ulcer: Left gastric artery (lesser curvature)
  • Duodenal ulcer: ★ Gastroduodenal artery (posterior wall)
  • Presentation: Hematemesis, melena, hematochezia (if brisk)
  • Management: IV PPI, endoscopy within 24 hours
Perforation (5%)
  • ★ Most common site: Anterior duodenal wall
  • Presentation: ★ Sudden severe pain, rigid abdomen, free air
  • Management: NPO, NG suction, IV antibiotics, urgent surgery
Penetration (rare)
  • Posterior duodenal → pancreas: ★ Pain radiating to back
  • Gastric → left lobe of liver
  • Diagnosis: ↑ Amylase/lipase, CT scan
Obstruction (2%)
  • Location: ★ Pyloric channel or duodenal bulb
  • Presentation: Vomiting undigested food, succussion splash
  • Management: NG decompression, PPI, endoscopic dilation
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HIGH-YIELD FACTS BOX - v2

 

  • ★ Most common cause overall: H. pylori infection (90% of duodenal ulcers, 70% of gastric ulcers)
  • ★ Second most common cause: NSAIDs
  • ★ Classic presentation: Epigastric burning pain
  • ★ Best initial test: Urea breath test or stool antigen (for H. pylori)
  • ★ Most accurate test: EGD with biopsy
  • ★ First-line treatment: Triple therapy (PPI + clarithromycin + amoxicillin)
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Memory Aids & Mnemonics - v2

📚 HIGH-YIELD MEMORY AIDS:
1. "GUDA" - Gastric vs Duodenal Ulcers:
  • Gastric = Greater with meals (pain)
  • Ulcer
  • Duodenal = Decreases with meals (pain)
  • Also occurs at night (duodenal)

2. "NSAID" - Complications of NSAIDs:

  • Nephropathy
  • Stomach ulcers
  • Asthma exacerbation
  • Interstitial nephritis
  • Dyspepsia

3. Alarm symptoms = "VBAD NEWS":

  • Vomiting (persistent)
  • Bleeding/Black stools
  • Anemia
  • Dysphagia
  • New onset >55 years
  • Early satiety
  • Weight loss
  • Swallowing difficulty
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Clinical Pearls - v2

💡PEARLS:

  • ★ Duodenal ulcers almost never malignant (<0.5%) - biopsy not routine
  • ★ Gastric ulcers require biopsy - 3-5% are malignant
  • ★ Pain relief with antacids suggests PUD but doesn't differentiate gastric from duodenal
  • ★ NSAIDs can cause ulcers without H. pylori
  • ★ Stop PPI 2 weeks before H. pylori testing to avoid false negatives
  • ★ Posterior duodenal ulcers → hemorrhage; Anterior → perforation
  • ★ Zollinger-Ellison: Think when ulcers in unusual locations (jejunum) or multiple ulcers
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Quick Review Box -v2

✅ MUST-KNOW FOR EXAMS:

  1. Most common cause of PUD: H. pylori (90% duodenal, 70% gastric)
  2. Classic duodenal ulcer: Young male, pain relieved by food, nocturnal pain
  3. Classic gastric ulcer: Elderly, pain worsened by food, weight loss
  4. Best initial H. pylori test: Urea breath test or stool antigen
  5. Triple therapy: PPI + clarithromycin + amoxicillin × 14 days
  6. Most common complication: Hemorrhage (gastroduodenal artery for duodenal)
  7. Perforation sign: Free air under diaphragm on CXR
  8. Always biopsy: Gastric ulcers (malignancy risk 3-5%)
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