Peptic ulcer

Condition

• Peptic ulcer 

Definitions

• a break in the lining of the stomach typically in the stomach or duodenum 

Main features

• Epigastric pain or discomfort 
• nausea
• vomiting 
• heartburn 
• nocturnal waking with epigastric pain 
• An ulcer diagnosis is more likely if there is a family history of ulcer disease or if the patient its making aspirin or another NSAID, and even more so if there is a documented past history of an ulcer

Investigations

• Office base: none 
• Pathology test: FBE, UEC, LFT, Lipase to look for anaemia and exclude other pathologies such as pancreatitis or hepatitis 
• Imaging: probably not useful but one of the surgeons I know always order one before endoscopy 
• Endoscopy provides the definite diagnosis. Biopsy can help to determine whether H. Pylori is present or not. Antibiotics within the last 4 weeks, or proton pump inhibitor therapy within the past 2 weeks, reduce the accuracy of these biopsies. 

Management 

• In uncomplicated duodenal ulcer, If H.Pylori is present, eradication. First line therapy is triple therapy. 
• Omeprazole 20 mg orally twice daily for 7 days 
• Amoxycillin 1g orally twice daily for 7 days
• Clarithromycin 500 mg twice daily for 7 days 
• If patient is hypersensitive to penicillin, metronidazole may be substitued for amoxycillin
• Omeprazole 20 mg orally twice daily for 7 days
• Metronidazole 400 mg orally twice daily for 7 days
• Clarithromycin 500 mg orally twice daily for 7 days 
• Post treatment test
• C13 or C14 urea breath test is preferred
• No antibiotics or bismuth 1 month before the test
• PPI should be suspended for at least 1 week 
• Follow up endoscopy is usually not required, exceptions are for gastric ulcer and complicated duodenal ulcers)
• For more complicated ulcers, large gastric ulcers, ulcers occurring in high risk patients or ulcers associated with NSAID use, ongoing antisecretory therapy with a PPI for about 8 weeks is appropriate.

References:

• John Murtagh 5th edition genenral practice 
• eTG