Peptic Ulcer Disease

PUD Essentials - Defining the Damage

• Definition: Peptic Ulcer Disease (PUD) is a defect in the gastric or duodenal mucosa extending through the muscularis mucosae, typically ≥ 5 mm in diameter.
• Locations:
  • Duodenal Ulcers (DU): Commonest; usually 1st part of duodenum (D1), anterior wall.
  • Gastric Ulcers (GU): Often lesser curvature; Type I most common.
• Pathophysiology: Imbalance between mucosal aggressive factors (acid, pepsin, H. pylori, NSAIDs) and defensive mechanisms (mucus-bicarbonate layer, prostaglandins, blood flow, epithelial regeneration).
  • ⭐ > Most common cause of PUD is H. pylori infection, followed by NSAID use.
• Other causes: Zollinger-Ellison Syndrome (gastrinoma), stress ulcers (Cushing's - ↑ intracranial pressure; Curling's - burns).

Pathophysiology & Symptoms - The Ulcer's Tale

• Pathophysiology: Imbalance: Aggressive factors (acid, pepsin, H. pylori, NSAIDs) overwhelm mucosal defensive factors (mucus, bicarbonate, prostaglandins, blood flow).
  • H. pylori: Spiral-shaped; urease (NH₃ → local ↑pH → ↑gastrin → ↑acid). Virulence: CagA, VacA.
  • NSAIDs: Inhibit COX-1 → ↓prostaglandins → ↓mucosal defense & repair.
  • ZES: Gastrinoma → hypergastrinemia → ↑↑acid.
• Symptoms:
  • Epigastric pain: Burning, gnawing. Timing with meals key.

  ⭐ Duodenal ulcer pain classically improves with meals (food buffers acid), while gastric ulcer pain worsens (food stimulates acid).

  • Gastric Ulcer (GU): Pain ↑ with meals. Nausea, vomiting, weight loss.
  • Duodenal Ulcer (DU): Pain ↓ with meals, recurs 2-3 hrs postprandial. Night pain common.
  • Alarm: Bleeding (melena/hematemesis), anemia, weight loss, persistent vomiting, dysphagia.

Diagnosis & H. pylori - Unmasking the Culprit

• Endoscopy (OGD): Gold standard. Biopsy for H. pylori & malignancy (gastric ulcers).
• Barium Meal: If endoscopy contraindicated.

H. pylori Tests:

• Invasive (via Endoscopy):
  • Rapid Urease Test (RUT): Quick, common.
  • Histology: High sensitivity/specificity.
  • Culture: For resistance.
• Non-invasive:
  • Urea Breath Test (UBT): Diagnosis & eradication confirmation (stop PPI/Abx 4 wks prior).
  • Stool Antigen Test (SAT): Similar to UBT.
  • Serology (IgG): Exposure only, not for eradication check.

⭐ Upper GI endoscopy with biopsy is the gold standard for diagnosing PUD and allows for H. pylori testing and malignancy exclusion in gastric ulcers.

Treatment & Complications - Mending & Monitoring

• H. pylori Eradication (Key):
  • Triple Therapy: PPI + Clarithromycin + Amoxicillin for 14 days.
  • Quadruple Therapy (Bismuth/Non-Bismuth) for resistance/failure.
• Acid Suppression:
  • Proton Pump Inhibitors (PPIs): e.g., Omeprazole 20-40mg OD.
  • H2 Receptor Antagonists (H2RAs).
• Lifestyle: Avoid NSAIDs, smoking, alcohol.
• Surgery (Rare): For refractory ulcers or complications (e.g., vagotomy, antrectomy).

Key Complications (see flowchart):

• Key Complications (details):
  • Bleeding (most common): Endoscopic Rx, IV PPI.
  • Perforation: Surgical emergency.
  • Gastric Outlet Obstruction (GOO): Dilation/surgery.
  • Penetration: Into adjacent organs.
• Monitoring:
  • Symptom relief.
  • Gastric ulcer: repeat endoscopy (r/o malignancy).
  • H. pylori test-of-cure (UBT/SAT).

⭐ Standard first-line triple therapy for H. pylori eradication includes a PPI + Clarithromycin + Amoxicillin for 14 days.

High‑Yield Points - ⚡ Biggest Takeaways

• H. pylori and NSAIDs are primary causes of Peptic Ulcer Disease (PUD).
• Duodenal ulcers: pain relieved by meals; Gastric ulcers: pain worsened by meals.
• Urea breath test or stool antigen test for H. pylori eradication confirmation.
• Standard triple therapy (PPI + two antibiotics) for H. pylori eradication is crucial.
• Major complications include bleeding (most common), perforation, and gastric outlet obstruction.
• Suspect Zollinger-Ellison syndrome with multiple or refractory ulcers.
• Endoscopy is diagnostic gold standard and allows for biopsy_._