QuestionSBA
QuestionChoice
GORD can present with dyspepsia, but it more typically presents with retrosternal pain and a bitter, acidic taste in the mouth. Pain associated with GORD typically gets worse, not better, after meals
33601
d
Gastro-oesophageal reflux disease (GORD)
QuestionChoice
Duodenal ulcers are the most common type of peptic ulcer. 90% of them are related to H. pylori infection. They are typically improved by eating and worsened a few hours after meals or when the patient is hungry. They may present with epigastric tenderness on examination. All suspected ulcers should be investigated for _H. pylori_, the positive urea breath test, in this case, indicating _H. pylori_ as the primary cause. Other common causes include NSAIDs and corticosteroids. First-line treatment of _H. pylori_ associated duodenal ulcers is eradication therapy using a one week course of amoxicillin, clarithromycin and a PPI, e.g. omeprazole. They should be tested 4-8 weeks later to ensure eradication
33598
a
Duodenal ulcer
QuestionChoice
Gastric ulcers are peptic ulcers in the gastric mucosa. Gastric ulcers and duodenal ulcers have very similar risk factors, including H. pylori. Gastric ulcers are typically exacerbated upon eating, whereas in this case, eating relieves these symptoms. These symptoms are more typical of a duodenal ulcer; therefore this is the most likely diagnosis
33599
b
Gastric ulcer
QuestionChoice
Gastric cancer can present with dyspepsia. However, it is an exceedingly rare diagnosis in a 24-year-old and would usually have red flag symptoms such as weight loss, vomiting or loss of appetite. Of note, mucosa-associated lymphoid tissue (MALT) lymphoma is a rare non-Hodgkin's lymphoma associated with H. pylori infection. However, given the typical temporal relation of symptoms to eating and the rarity of MALT lymphoma, duodenal ulcers are the most likely diagnosis
33600
c
Gastric cancer
QuestionChoice
Biliary colic typically occurs after a heavy, fatty meal. This patient also isn't in the typical demographics, with biliary colic typically affecting middle-aged women with a high BMI. As eating makes this pain better, and this patient has _H. pylori_, a diagnosis of duodenal ulcer is more likely
33602
e
Biliary colic
QuestionComment
difference between CLO test and urea breath test? and also why is stool antigen test not done for H Pylori at all?
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subscriber
Acute Sclerosis
Concept
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# Summary

Peptic ulcer disease, encompassing both duodenal and gastric ulcers, is a condition where the stomach lining's self-protection mechanisms fail, often due to the presence of external factors like H. Pylori. Key signs and symptoms include pain, nausea, vomiting and loss of appetite. The primary investigation tool is endoscopy, which allows for a direct visual inspection of the ulcers. Management strategies include both pharmaceutical interventions, such as PPI treatment, and lifestyle changes, like cessation of smoking and dietary adjustments.

# Definition

Peptic ulcer disease refers to painful sores or ulcers in the lining of the stomach or the first part of the small intestine, known as the duodenum. The frequency of duodenal ulcers is four times higher than that of gastric ulcers. It is an endoscopic diagnosis (NB: dyspepsia is a clinical diagnosis). Peptic ulcer disease can be uncomplicated, or complicated (perforation, bleeding).

# Epidemiology

Peptic ulcer disease is a common condition, with the prevalence of duodenal ulcers being four times that of gastric ulcers. It's noteworthy that approximately 90% of duodenal ulcers are caused by H. Pylori infection.

# Aetiology

The primary cause of duodenal ulcers is the infection by H. Pylori. Other factors contributing to the development of these ulcers include:

- NSAIDs
- Chronic use of steroids
- SSRIs
- Increased secretion of gastric acid
- Smoking
- Blood group O
- Accelerated gastric emptying  

For gastric ulcers, the risk factors include:

- NSAIDs
- H. Pylori infection
- Smoking
- Delayed gastric emptying
- Severe stress

# Signs and Symptoms

Patients with peptic ulcer disease may present with:

- Abdominal pain
- Nausea
- Vomiting
- Loss of appetite
- Unexplained weight loss
- Patients with complicated peptic ulcer disease may present with coffee ground vomiting (bleeding), and can be haemodynamically unstable due to perforation

Duodenal ulcers typically present with epigastric pain typically relieved on eating (closure of pyloric sphincter, less acid irritating ulcerated surface). Symptoms of gastric ulcers on the other hand are often worsened by eating - stomach increases acid production in response to food and irritates ulcerated surface.

# Differential Diagnosis

The symptoms of peptic ulcer disease can mimic those of other conditions, including:

- Gastritis: inflammation of the stomach lining, presenting with nausea, vomiting, and abdominal discomfort.
- Gastro-oesophageal reflux disease (GORD): chronic acid reflux, characterized by heartburn, regurgitation, and swallowing difficulties.
- Stomach cancer: may cause similar symptoms, but often accompanied by significant weight loss, loss of appetite, and anemia.

# Investigations

- Patients >55 with weight loss and dyspepsia should be referred for an urgent OGD (within 2 weeks) to investigate for oesophageal and gastric cancer
- Patients should be investigated for H.pylori infection with C-13 urea breath test (ensure the person has not taken a PPI in the past 2 weeks, or antibiotics in the past 4 weeks)
- Investigation tools for peptic ulcer disease primarily include endoscopy, which allows a direct visual inspection of the ulcers. Biopsies may be taken to rule out malignancy.

# Management

Management of H. Pylori-negative peptic ulcer disease involves a 4-8 week course of full-dose PPI treatment in conjunction with lifestyle advice, such as:

- Smoking cessation
- Reducing alcohol intake
- Regular, small meals and avoiding eating 4 hours before bedtime
- Avoidance of acidic, fatty or spicy foods, and coffee
- Weight loss if overweight 
- Stress management
- Avoidance of NSAIDs, steroids, bisphosphonates, potassium supplements, SSRIs, and crack cocaine
- Over-the-counter antacids


- If the patient is H.pylori positive with a proven gastric/duodenal ulcer which is:
	- Associated with NSAID use: 8 week PPI therapy followed by first-line eradication therapy - PPI (omeprazole/lansoperazole) + amoxicillin + clarithromycin/metronidazole for 7 days
		- If penicillin allergic, offer: PPI + clarithromycin + metronidazole for 7 days 
	- Not associated with NSAID use: eradication therapy with PPI (omeprazole/lansoperazole) + amoxicillin + clarithromycin/metronidazole for 7 days
	- If the person is allergic to pencillin and has had previous exposure to clarithromycin, offer a 7-day quadruple therapy regimen of:
PPI + metronidazole + tetracycline hydrochloride + bismuth subsalicylate

- For patients with gastric ulcers, a repeat endoscopy 6-8 weeks following the start of PPI treatment is recommended to ensure ulcer healing and rule out malignancy, as well as H.pylori re-testing (C-13 urea breath test first-line, stool antigen test second line) if appropriate.
- Complicated peptic ulcer disease requires urgent surgical intervention with OGD for underunning of ulcers and haemostasis
	- Perforated peptic ulcers present initially with localised epigastric pain which later becomes generalised and peritonitic. These patients require an AXR and erect CXR to look for pneumoperitoneum. 

# NICE Guidelines

[Click here to see more information NICE CKS on peptic ulcer disease](https://cks.nice.org.uk/topics/dyspepsia-proven-peptic-ulcer/management/management-proven-peptic-ulcer/)
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Peptic ulcer disease
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Gastroenterology
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Peptic ulcer disease
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Approach to Epigastric pain
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A 24-year-old male presents to the GP with a one-month history of epigastric pain. This gets better after he eats a meal but is at its worst again a few hours later. On examination, the abdomen is soft with tenderness in the epigastrium. A urea breath test is performed, which is positive.

What is the most likely diagnosis?
a