Gastroenterology & Hepatology
A 37 year old man presents to the Emergency Department with a 2 day history of epigastric pain. He tells you he has had similar episodes over the last 8 weeks. He denies weight loss, vomiting or any bowel symptoms. He visited his General Practitioner last week who "did some tests", but he is yet to receive any results. You can see on the hospital computer system a H.pylori breath test was positive. Which H.pylori eradication regimen is appropriate?
Answer:
First-line Helicobacter pylori eradication regimens consist of a proton pump inhibitor (PPI) together with a combination of antibiotics (taking into account previous exposure to clarithromycin or metronidazole). Ensure the person is aware of the importance of compliance with the prescribed regimen. Offer a 7-day triple therapy regimen of: a PPI twice daily and amoxicillin 1 g twice daily and either clarithromycin 500 mg twice-daily or metronidazole 400 mg twice-daily.Peptic Ulcer Disease
Gastroenterology & Hepatology
Last Updated: 12th February 2021
Gastric or duodenal ulceration describes a breach in the epithelium of the gastric or duodenal mucosa that penetrates the muscularis mucosae, which is confirmed on endoscopy.
Risk factors
Risk factors for the development of peptic ulcer disease include:
- Helicobacter pylori infection
- 95% of duodenal and 70–80% of gastric ulcers are associated with H. pylori infection.
- Infection causes increased gastric acid secretion in some cases, which increases the risk of mucosal ulceration. In other cases, gastric acid secretion is decreased causing chronic atrophic gastritis, which increases the risk of gastric ulceration and possible gastric malignancy.
- Drugs
- Such as nonsteroidal anti-inflammatory drugs (NSAIDs), aspirin, bisphosphonates, corticosteroids, potassium supplements, selective serotonin reuptake inhibitors (SSRIs), and recreational drugs such as crack cocaine.
- NSAIDs and aspirin are the main drugs associated with the development of peptic ulcer disease. NSAIDs increase the risk of complications of peptic ulcer disease four-fold, and aspirin use doubles the risk of complications.
- Smoking, alcohol consumption, and stress
- Zollinger-Ellison syndrome (rare) — this hypersecretory state may be associated with multiple peptic ulcers, diarrhoea, weight loss, and hypercalcaemia
Diagnosis
A common clinical feature is dyspepsia, a complex of upper gastrointestinal tract symptoms which are typically present for four or more weeks, including upper abdominal pain or discomfort, heartburn, acid reflux, nausea and/or vomiting. There may be some epigastric tenderness on palpation of the abdomen, but often there are no other signs on examination.
In patients aged ≥60 years (≥55 years with associated weight loss) presenting with dyspepsia, an endoscopy should be ordered. Endoscopy is diagnostic and may show an ulcer in the stomach or proximal duodenum. Patients aged under 60 years with dyspeptic symptoms should have H pylori testing.
Differential diagnosis
- Other causes of dyspepsia:
- Gastro-oesophageal reflux disease (GORD)
- Functional dyspepsia (non-ulcer dyspepsia)
- Barrett's oesophagus
- Upper gastrointestinal malignancy
- Other causes which may present with dyspepsia-like symptoms:
- Gallbladder or hepatobiliary disease
- Pancreatic disease
- Cardiac disease
- Gastroenteritis
- Coeliac disease
- Crohn's disease
- Irritable bowel syndrome
- Abdominal aortic aneurysm (rare).
Management
- Offer advice on lifestyle measures which may improve symptoms:
- Lose weight if they are overweight or obese.
- Avoid any trigger foods, such as coffee, chocolate, tomatoes, fatty or spicy foods.
- Eat smaller meals and eat their evening meal 3–4 hours before going to bed, if possible.
- Stop smoking, if appropriate.
- Reduce alcohol consumption to recommended limits, if appropriate.
- Advise the person to stop any nonsteroidal anti-inflammatory drugs (NSAIDs) completely, if possible and appropriate, to allow ulcer healing. Consider reducing or stopping (if possible and appropriate) any other potential ulcer-inducing drugs, such as: aspirin, bisphosphonates, corticosteroids, potassium supplements, selective serotonin reuptake inhibitors (SSRIs), or recreational drugs such as crack cocaine.
- Test the person for H. pylori infection if their status is not known or uncertain. For the initial detection of H. pylori infection, arrange a carbon-13 urea breath test or stool antigen test (ensure the person has not taken a PPI in the past 2 weeks, or antibiotics in the past 4 weeks). Arrange laboratory serological testing if these options are not available, providing the test has been locally validated.
- If the person tests positive for H. pylori infection with a proven gastric or duodenal ulcer which is:
- Associated with NSAID use — prescribe full-dose PPI therapy for 2 months, then prescribe first-line eradication therapy after completion of PPI therapy.
- Not associated with NSAID use — prescribe first-line eradication therapy.
- If the person tests negative for H. pylori infection with a proven gastric or duodenal ulcer:
- Prescribe full-dose PPI therapy for 4–8 weeks, depending on clinical judgement.
- First-line Helicobacter pylori eradication regimens consist of a proton pump inhibitor (PPI) together with a combination of antibiotics (taking into account previous exposure to clarithromycin or metronidazole). Ensure the person is aware of the importance of compliance with the prescribed regimen. Offer a 7-day triple therapy regimen of: a PPI twice daily and amoxicillin 1 g twice daily and either clarithromycin 500 mg twice-daily or metronidazole 400 mg twice-daily.
- Ensure all people with a proven gastric ulcer have a repeat endoscopy to confirm healing and Helicobacter pylori re-testing (if appropriate) arranged 6–8 weeks after starting first-line H. pylori eradication and/or proton pump inhibitor (PPI) therapy.
Complications
The risk of complications of peptic ulcer disease is increased in older age groups, people with comorbidities, and people taking medication such as nonsteroidal anti-inflammatory drugs (NSAIDs) or anticoagulants. Possible complications include:
- Haemorrhage — acute massive haemorrhage may be life-threatening with a case fatality rate of 5–10%, and chronic bleeding may cause iron deficiency anaemia.
- Perforation — this may cause peritonitis which may be life-threatening, with a mortality rate of up to 20%.
- Gastric outlet obstruction — this may result from strictures and stenosis of the pylorus and/or duodenum due to chronic inflammation and scarring.
- Gastric malignancy — there is an increased risk in Helicobacter pylori positive gastric ulcer disease.
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
