What are the symptoms and treatment options for peptic ulcer disease?

Symptoms and Treatment of Peptic Ulcer Disease

The most common symptom of peptic ulcer disease is epigastric pain, which may be relieved by food, milk, or antacids, and is often associated with dyspepsia, bloating, abdominal fullness, nausea, or early satiety. 1, 2

Common Symptoms

• Epigastric discomfort or pain that is typically relieved by food intake or antacids 3
• Pain that awakens patients at night or occurs between meals 3
• Postprandial abdominal pain 4
• Nausea and vomiting 4
• Weight loss 3
• Loss of appetite 3
• Approximately two-thirds of patients with peptic ulcer disease may be asymptomatic 2

Complications and Their Presentations

• Bleeding (73% of patients with complications) 1
• Perforation (9% of patients with complications) - presents with sudden onset of abdominal pain and localized or generalized peritonitis 1, 5
• Pyloric obstruction (3% of patients with complications) 1
• In perforated peptic ulcer, peritonitis may be present in only two-thirds of patients, making physical examination findings potentially equivocal 5

Diagnostic Approach

• Endoscopy is the gold standard for diagnosis, especially in older patients and those with alarm symptoms 4, 1
• For younger patients with no alarm symptoms, a test-and-treat strategy for H. pylori is recommended 3, 4
• Laboratory tests are non-specific, though leukocytosis, metabolic acidosis, and elevated serum amylase may be present in complicated cases 5
• CT scan is strongly recommended as the first radiological examination in patients with suspected perforated peptic ulcer 5
• Chest/abdominal X-ray should be performed as initial diagnostic assessment when CT is not immediately available 5

Treatment Options

Eradication of H. pylori

• H. pylori infection affects approximately 42% of patients with peptic ulcer disease 1

• Eradication of H. pylori decreases peptic ulcer recurrence rates from 50-60% to 0-2% 1

• Standard triple therapy (amoxicillin, clarithromycin, and PPI) is recommended as first-line therapy if low clarithromycin resistance is present 6

  • PPI standard dose twice a day
  • Clarithromycin 500 mg twice a day
  • Amoxicillin 1000 mg twice a day

• Sequential therapy with four drugs (amoxicillin, clarithromycin, metronidazole, and PPI) is recommended in cases of high clarithromycin resistance 6

• A 10-day levofloxacin-amoxicillin triple therapy is recommended as second-line therapy if first-line therapy fails 6

Management of NSAID-Related Ulcers

• NSAIDs are etiologic factors in approximately 36% of people with peptic ulcer disease 1
• Discontinuing NSAIDs heals 95% of ulcers identified on endoscopy and reduces recurrence from 40% to 9% 1
• When discontinuing an NSAID is not possible 1:
  • Change to a less ulcerogenic NSAID
  • Add a proton pump inhibitor
  • Eradicate H. pylori if present

Acid Suppression Therapy

• Proton pump inhibitors (PPIs) are the primary treatment for peptic ulcer disease 1, 4
• Acid blockers such as omeprazole can heal peptic ulcers in approximately 80-100% of patients within 4 weeks 1
• Gastric ulcers larger than 2 cm may require 8 weeks of treatment 1
• Full dose PPI therapy (e.g., omeprazole 20 mg once daily) is the first choice of therapy in patients with ulcer-like dyspepsia 6

Management of Complications

• Bleeding is the most common indication for surgery 3
• Administration of proton pump inhibitors and endoscopic therapy control most bleeds 3
• Perforation and gastric outlet obstruction are rare but serious complications 3
• Peritonitis from perforation is a surgical emergency requiring 3:
  • Patient resuscitation
  • Laparotomy and peritoneal toilet
  • Omental patch placement
  • In selected patients, surgery for ulcer control

Follow-up and Prevention

• At least 4 weeks after treatment, repeat testing for H. pylori should be obtained to confirm cure 4
• If symptoms are controlled by an initial course of empirical therapy, a trial of withdrawal of therapy should be considered, with therapy repeated in case of symptom recurrence 6
• On-demand therapy with the successful agent is a further option 6

Common Pitfalls

• Symptoms of peptic ulcer disease have broad overlap with other conditions, making clinical diagnosis difficult 4
• Up to 12% of patients with perforations may have a normal CT scan, requiring additional diagnostic measures 5
• Patients who do not respond to the first choice of symptomatic therapy may have been misclassified and should be considered for a switch of treatment 6