Patients that don’t respond to PPI trial are warranted a full investigation to identify peptic ulcers, H. pylori and R/O malignancy of the stomach and esophagus, using: CBC and stool occult blood Endoscopy with biopsy (especially in older patients) Urea breath test/serology/stool Ag Medical management is warranted if peptic ulcer disease is the definitive diagnosis Avoid smoking, alcohol, NSAIDs Use of antacids to relieve symptoms PPI for isolated ulcers (no H pylori) H. pylori +ve triple therapy (PPI + amoxicillin + clarithromycin) or quadruple therapy (PPI + tetra + metro + bismuth) Surgical management is only indicated in PUD if “ICHOP”: Intractable to medical Rx Cancer possibility (in gastric ulcers) Hemorrhagic features Outlet obstruction (GOB) Perforated peptic ulcer (usually duodenal) Peptic ulcer disease Acute ulcer disease (usually secondary to gastritis) NSAIDs use (hemorrhagic gastritis) Stress ulcers (in ICU patients, shocked patients) Cushing ulcers (in increased ICP, probably increased vagal tone) Curling ulcers (in burn patients) Chronic ulcer disease (classic peptic ulcer disease) Risk factors: Family history Smoking and alcohol use Age (DU occurs at age 40s-50s; GU later ages) H. pylori infection Chronic NSAIDs use Chronic steroid use Possible causes to consider: Hypercalcemia (hyperparathyroidism) Zollinger-Ellison syndrome (suspected when intractable and on endoscopy many ulcers are seen, even in jejunum; gastrin levels are >1000 pg/mL = pathognomonic)
Patients that don’t respond to PPI trial are warranted a full investigation to identify peptic ulcers, H. pylori and R/O malignancy of the stomach and esophagus, using: CBC and stool occult blood Endoscopy with biopsy (especially in older patients) Urea breath test/serology/stool Ag Medical management is warranted if peptic ulcer disease is the definitive diagnosis Avoid smoking, alcohol, NSAIDs Use of antacids to relieve symptoms PPI for isolated ulcers (no H pylori) H. pylori +ve triple therapy (PPI + amoxicillin + clarithromycin) or quadruple therapy (PPI + tetra + metro + bismuth) Surgical management is only indicated in PUD if “ICHOP”: Intractable to medical Rx Cancer possibility (in gastric ulcers) Hemorrhagic features Outlet obstruction (GOB) Perforated peptic ulcer (usually duodenal) Peptic ulcer disease Acute ulcer disease (usually secondary to gastritis) NSAIDs use (hemorrhagic gastritis) Stress ulcers (in ICU patients, shocked patients) Cushing ulcers (in increased ICP, probably increased vagal tone) Curling ulcers (in burn patients) Chronic ulcer disease (classic peptic ulcer disease) Risk factors: Family history Smoking and alcohol use Age (DU occurs at age 40s-50s; GU later ages) H. pylori infection Chronic NSAIDs use Chronic steroid use Possible causes to consider: Hypercalcemia (hyperparathyroidism) Zollinger-Ellison syndrome (suspected when intractable and on endoscopy many ulcers are seen, even in jejunum; gastrin levels are >1000 pg/mL = pathognomonic)
GS+notes.docx