What are the symptoms and treatment options for peptic ulcers?

Symptoms and Treatment of Peptic Ulcers

The most common symptom of peptic ulcer disease is sudden onset of epigastric abdominal pain, which may be accompanied by localized or generalized peritonitis, though peritonitis may be present in only two-thirds of patients with perforated ulcers. 1 Other common symptoms include dyspepsia, bloating, abdominal fullness, nausea, early satiety, loss of appetite, and weight loss 2, 3.

Clinical Presentation

Common Symptoms

• Epigastric pain (most characteristic symptom)
  • Often relieved by food intake or antacids
  • May cause awakening at night
  • May occur between meals
• Dyspepsia
• Bloating
• Abdominal fullness
• Nausea
• Early satiety
• Loss of appetite
• Weight loss

Warning Signs (Alarm Symptoms)

• Sudden onset of severe abdominal pain (suggests perforation)
• Melena (black, tarry stools indicating bleeding)
• Hematemesis (vomiting blood)
• Unexplained weight loss
• Persistent vomiting
• Anemia

It's important to note that approximately two-thirds of patients with peptic ulcer disease may be asymptomatic 2, making diagnosis challenging in these cases.

Diagnostic Approach

Initial Evaluation

• Laboratory studies: Complete blood count, comprehensive metabolic panel, and arterial blood gas analysis 1
• Imaging:
  • CT scan is recommended as first-line imaging for suspected perforated peptic ulcer 1
  • Chest/abdominal X-ray if CT is not promptly available 1
  • Water-soluble contrast studies (oral or via nasogastric tube) when free air is not seen but suspicion remains high 1

Definitive Diagnosis

• Upper endoscopy (EGD) is the gold standard for diagnosis 4, 2
  • Should be performed urgently (within 24 hours) in cases of active bleeding 4
  • Allows for both diagnosis and potential therapeutic intervention

Treatment Approach

Medical Management

1. Proton Pump Inhibitors (PPIs)

   • First-line treatment for peptic ulcer disease 5, 6
   • Omeprazole 20mg daily can heal 75% of duodenal ulcers within 4 weeks 5
   • Gastric ulcers larger than 2cm may require 8 weeks of treatment 6
   • PPIs should be started immediately while awaiting endoscopy for bleeding ulcers 4

2. Helicobacter pylori Eradication (if H. pylori positive)

   • Triple therapy: PPI + clarithromycin + amoxicillin for 10-14 days 5, 7
   • Eradication reduces ulcer recurrence rates from 50-60% to 0-2% 6
   • Testing for H. pylori is recommended in all patients with peptic ulcer disease 1

3. NSAID Management

   • Discontinue NSAIDs if possible (heals 95% of ulcers and reduces recurrence from 40% to 9%) 6
   • If NSAIDs must be continued:
     • Switch to less ulcerogenic NSAID
     • Add PPI for gastroprotection
     • Eradicate H. pylori if present 6

Endoscopic Treatment (for bleeding ulcers)

• Indicated for high-risk stigmata: active bleeding, visible vessel, or adherent clot 4
• Options include band ligation, sclerotherapy, or hemostatic clips 4

Angiographic Intervention

• For patients with ongoing bleeding not amenable to endoscopic treatment 4
• Embolization techniques may be used 1

Surgical Management

• Indicated for complications or medication-unresponsive ulcers 3
• Common indications:
  • Bleeding (most common indication, 73% of cases) 6
  • Perforation (9% of cases) 6
  • Pyloric obstruction (3% of cases) 6
  • Failure of medical therapy

Prevention Strategies

1. H. pylori Eradication

   • Crucial for preventing recurrence in H. pylori-positive patients 6, 7

2. PPI Maintenance Therapy

   • Consider for patients with recurrent disease or those who have experienced complications 8
   • Duration varies based on risk factors and history

3. Lifestyle Modifications

   • Smoking cessation (smoking impairs healing and increases recurrence) 8
   • Avoid or minimize NSAID use when possible
   • Stress management

4. Follow-up

   • Repeat endoscopy after 8 weeks of PPI therapy for severe erosive disease 4
   • Individualized follow-up based on specific diagnosis and risk factors

Special Considerations

Complications to Monitor

• Bleeding (most common complication)
• Perforation (surgical emergency requiring immediate intervention)
• Gastric outlet obstruction
• Peritonitis

Medication Side Effects

• PPI long-term use concerns:
  • Potential for vitamin B12 deficiency 5
  • Hypomagnesemia (rare but serious) 5
  • Increased risk of fundic gland polyps with prolonged use 5
  • Potential for cutaneous and systemic lupus erythematosus 5

Peptic ulcer disease remains a significant cause of morbidity and mortality, with approximately 10,000 deaths annually in the US 6. Early diagnosis and appropriate treatment are essential to prevent complications and improve outcomes.