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Snap Shot
  • A 65-year-old-male presents with complaints of epigastric pain and belching, which improves when he eats food, but gets worse within a few hours after his meal. He said he has noticed a change in the color of his stool.
Introduction
  • Painful sores or ulcers in the lining of the stomach or duodenum
    • breach in the mucosa with extension into the submucosa or deeper 
  • Occurs when gastric acid secretion outweighs mucosal defenses
    • most commonly due to decreased mucosal barrier
      • NSAIDs
      • H.pylori
      • smoking
    • less commonly due to acid hypersecretion
      • such as gastrinoma (Zollinger-Ellison syndrome)
Classification
  • Duodenal ulcers  
    • more common, usually in first part of duodenum
      • typically due to H. pylori, which infects the antrum of the stomach and causes increased acid in the duodenum 
    • low risk of malignancy 
    • caused by acid hypersecretion or ↓ mucosal barrier
  • Gastric ulcers
    • less common, usually in lesser curvature of stomach
    • higher risk of malignancy
    • not caused by acid hypersecretion
Presentation
  • Duodenal ulcer 
    • chronic dull, burning, aching epigastric pain that may radiate to the back
    • improves with meals, but worsens 1-3 hours after eating
    • awaken patient at night
  • Gastric ulcer
    • midepigastric, gnawing pain
    • worse with meals
  • Physical exam
    • ulcer perforations can present with
      • pain in right shoulder 
      • rebound tenderness
      • ileus as a result of chemical peritonitis
      • peritoneal signs secondary to acute perforation
Evaluation
  • H. pylori
    • see Gastritis topic 
  • Upper endoscopy
    • must have biopsy to rule out malignancy in gastric ulcers
    • do not need to biopsy duodenal ulcers
    • non-malignant appearance has "punched-out" margins
    • malignant appearance has raised/irregular margins
  • Serology
    • serum gastrin to rule out Zollinger-Ellison syndrome
Treatment
  • Lifestyle
    • discontinue smoking and NSAIDs
  • Pharmacologic
    • mucosal protectors
      • bismuth
      • sucralfate
      • misoprostol
    • acid control
      • proton pump inhibitors (PPI's) 
      • H2 receptor antagonist 
    • antibiotics
      • eradicate H. pylori
  • Surgical
    • parietal cell vagotomy
      • indicated in refractory duodenal cases
Complications
  • Gastric/duodenal perforations
    • abdominal radiograph will show "air under the diaphgram"
  • Hemorrhage
    • from left gastric artery in gastric ulcers
    • from gastroduodenal artery in duodenal ulcers
  • Gastric outlet obstruction
 

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