What are the signs, symptoms, investigations, and management options for a patient with peptic ulcer disease?

Peptic Ulcer Disease: Signs, Symptoms, Investigations, and Management

Clinical Presentation

Epigastric pain is the hallmark symptom of peptic ulcer disease, though approximately two-thirds of patients are asymptomatic. 1, 2

Key Signs and Symptoms

• Epigastric pain that is characteristically relieved by food intake or antacids, occurs between meals, or awakens patients at night 3
• Dyspepsia, bloating, abdominal fullness, nausea, or early satiety 1
• Loss of appetite and weight loss 3
• In perforated ulcers: sudden onset of abdominal pain with localized or generalized peritonitis, though peritonitis is present in only two-thirds of patients 4

Common Pitfall

Physical examination findings may be equivocal, and absence of peritonitis does not exclude perforation 4

Investigations

Endoscopy is the gold standard for diagnosis and should be the first-line diagnostic approach. 5, 4

Diagnostic Algorithm

For Uncomplicated Suspected Peptic Ulcer Disease

• Younger patients without alarm symptoms: Use a test-and-treat strategy based on H. pylori testing 3
• Older patients or those with alarm symptoms: Perform prompt endoscopy 3
• Risk stratification using Blatchford score determines timing of endoscopy: very low-risk patients undergo outpatient endoscopy, low-risk patients undergo early inpatient endoscopy, and high-risk patients undergo urgent inpatient endoscopy 5

For Suspected Perforated Peptic Ulcer

• CT scan is strongly recommended as the first radiological examination (Strong recommendation, 1C) 4
• CT findings include pneumoperitoneum, unexplained intraperitoneal fluid, bowel wall thickening, mesenteric fat streaking, and extraluminal contrast 4
• Chest/abdominal X-ray should be performed when CT is not immediately available (Strong recommendation, 1C), though free air is detected in only 30-85% of perforations 4
• Up to 12% of patients with perforations may have a normal CT scan, requiring additional diagnostic measures 4

Essential Laboratory Studies

• Routine laboratory studies and arterial blood gas analysis are strongly recommended in suspected perforation 4
• Laboratory findings are generally non-specific but may show leukocytosis, metabolic acidosis, and elevated serum amylase 4

H. pylori Testing

• All patients with peptic ulcers must be tested for H. pylori infection 5, 2
• Non-invasive testing includes urea breath test and stool antigen test 5
• Negative H. pylori tests obtained during acute bleeding should be repeated, as acute bleeding causes false-negative results 5

Critical Requirement for Gastric Ulcers

• Biopsy of all gastric ulcers is mandatory to exclude malignancy, as gastric ulcers cannot be reliably distinguished as benign by appearance alone 5
• Multiple biopsies should be obtained from the ulcer margin and base 5
• All gastric ulcers require repeat endoscopy at approximately 6 weeks to confirm healing and exclude malignancy 5

Common Pitfall

Failing to biopsy gastric ulcers is the most critical error, as malignancy cannot be excluded without histology 5

Management

Uncomplicated Peptic Ulcer Disease

Proton pump inhibitors (PPIs) are the primary treatment, healing peptic ulcers in 80-100% of patients within 4 weeks. 2

Medical Management Algorithm

1. Discontinue NSAIDs if applicable - this heals 95% of ulcers and reduces recurrence from 40% to 9% 2
2. Administer high-dose PPI therapy (e.g., omeprazole or lansoprazole) for 4 weeks for duodenal ulcers; gastric ulcers larger than 2 cm may require 8 weeks 2, 5
3. Eradicate H. pylori if present with combination therapy (e.g., bismuth, metronidazole, and tetracycline combined with omeprazole), which decreases ulcer recurrence from 50-60% to 0-2% 2, 5
4. Confirm H. pylori eradication after treatment 5
5. Continue PPI therapy until repeat endoscopy confirms healing 5

When NSAIDs Cannot Be Discontinued

• Change the NSAID to a less ulcerogenic agent (e.g., from ketorolac to ibuprofen) 2
• Add a proton pump inhibitor 2
• Eradicate H. pylori if present 2
• Patients requiring continued NSAID therapy should receive ongoing PPI therapy 5

Long-term Management

• Long-term acid suppression therapy is beneficial for chronic NSAID users and H. pylori-infected patients 6

Bleeding Peptic Ulcer Disease

Emergency endoscopy is the first-line management for bleeding peptic ulcers. 6

Initial Resuscitation

• Maintain hemoglobin >7 g/dL 5
• Target systolic blood pressure 90-100 mmHg 5
• Normalize lactate and base deficit 5
• Correct/prevent coagulopathy 5

Endoscopic Management

• Endoscopic treatment is recommended for spurting ulcers, oozing ulcers, and ulcers with non-bleeding visible vessels 5
• Dual modality endoscopic hemostasis is suggested 5
• Pre-endoscopy erythromycin enhances visualization and reduces the need for second endoscopy, though it does not reduce surgical intervention or impact mortality 6

Post-Endoscopic Management

• High-dose omeprazole (80 mg bolus injection, then 8 mg/h continuous infusion for 72 h) reduces recurrent bleeding, need for surgery, and mortality compared to standard-dose omeprazole 7
• PPIs are recommended for 6-8 weeks following endoscopic treatment to allow mucosal healing 6, 5
• Testing for H. pylori is recommended in all patients with bleeding peptic ulcer, followed by eradication therapy 6
• Recurrent bleeding occurs in 20% of patients after endoscopic therapy 7

Management of Recurrent Bleeding

• Emergency endoscopy is the first-line management for rebleeding peptic ulcer (Strong recommendation, 1C) 6
• Transcatheter angioembolization is suggested as an alternative when endoscopy fails or is not feasible in hemodynamically stable patients (Weak recommendation, 2D) 6, 5
• Angiography is a second-line investigation after negative endoscopy (Weak recommendation, 2C) 6

Common Pitfall

Performing angiography before endoscopy results in unacceptable rates of negative investigations and is not warranted given the invasive nature 5

Perforated Peptic Ulcer Disease

Surgical intervention is typically required for perforated peptic ulcers. 5

Surgical Management

• Peritonitis is a surgical emergency requiring patient resuscitation, laparotomy and peritoneal toilet, omental patch placement, and in selected patients, surgery for ulcer control 3

Indications for Surgery in Uncomplicated Disease

• Complications develop 3
• Ulcer is unresponsive to medications 3
• Bleeding is the most common indication for surgery, though most bleeds are controlled with PPIs and endoscopic therapy 3

Complications

• Bleeding affects 73% of patients with complications 2
• Perforation affects 9% of patients with complications 2
• Pyloric obstruction affects 3% of patients with complications 2
• Gastric outlet obstruction is rare but serious 3