QuestionSBA
QuestionChoice
GORD would usually be described as causing more of a burning epigastric/chest pain, rather than a sharp pain. It would also usually be improved with dietary modification such as eating smaller meals or cutting out spicy foods
33350
c
Gastro-oesophageal reflux disease (GORD)
QuestionChoice
Pain from gastric ulcers is classically exacerbated by food, and maximal within 30 minutes to an hour of eating a meal. In addition, this pathology is not easily identified on ultrasound, and would usually require an oesophageal-gastroduodenoscopy (OGD)
33348
a
Gastric ulcer
QuestionChoice
In biliary colic the pain is more cramping/"colic-y" in nature and is exacerbated specifically by fatty foods. In addition, patients may have a history of gallstones, most of which can be visualised on ultrasound
33352
e
Biliary colic
QuestionChoice
Pain from pancreatitis may radiate to the back and is also frequently accompanied by vomiting. In addition, most patients have a history that can identify a potential trigger, such as known gallstones, alcohol excess or pregnancy etc. (although it can be idiopathic!)
33351
d
Pancreatitis
QuestionChoice
Pain from duodenal ulcers is classically exacerbated by hunger and alleviated by food. This is thought to be due to acid levels in the duodenum, which is effectively "diluted" by the presence of food
33349
b
Duodenal ulcer
Concept
Chapter
# 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
Topic
23
Gastroenterology
Video
Concept
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Peptic ulcer disease
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DekGUen
images/videos/surgery.png
Approach to Epigastric pain
6670
A 22-year-old female presents to her GP with a three month history of sharp upper abdominal pain occurring shortly after eating. She has lost 5 kilograms in the last month due to limiting her food intake to minimise her pain. She has also tried to cut out various foods from her diet, including gluten, lactose, spicy foods and fatty foods, but has not managed to identify any triggers.

She was previously referred for an abdominal ultrasound, which has come back with no abnormality detected.

What is the most likely diagnosis?
a