Snapshot A 65-year-old male presents with complaints of epigastric pain and belching which improves when he eats food but gets worse a few hours after his meal. He said he has noticed a change in the color of his stool. Introduction Damage to the gastric or duodenal mucosa caused by: impaired mucosal defense acidic gastric contents Duodenal Ulcers more common caused by acid hypersecretion H. pylori highly associated with duodenal ulcers and gastric ulcers keep in mind a prominent cause of gastric ulcers is also NSAID use Gastric ulcers NOT caused by acid hypersecretion H. pylori in >70% of gastric ulcers Other causes include: NSAIDS corticosteroids tobacco ETOH Presentation Symptoms nausea hematemesis melena or hematochezia symptoms may very by ulcer location gastric ulcers midepigastic gnawing pain worse with meals duodenal ulcer chronic dull, burning, aching epigastric pain improves with meals worsens 1-3 hours after eating radiates to the back awaken patient at night Ulcer Perforation pain in right shoulder ( air under the diaphragm) rebound tenderness ileus occur as a result of chemical peritonitis Acute perforation may lead to peritoneal signs Evaluation Urease breath test used to diagnose H. pylori infection Serum gastrin used to rule out Zollinger-Ellison syndrome CXR used to rule out free air and perforation Upper Endoscopy with biopsy ulcers for > 2 mos. must have biopsy to rule out malignancy Differential GERD, CAD, gastritis, pancreatitis, cholecystitits, Zollinger-Ellison syndrome, aortic aneurysm, and other causes of an acute abdomen. Treatment Pharmacologic mucosal protectors bismuth sucrafate misoprostol acid control proton pump inhibitor (omeprazole) for 1-3 weeks H2 receptor antagonists for 1-2 months Tetracyline and clarithromycin (or Flagyl) for H. pylori Perforated ulcer: requires intravenous antibiotics and proton pump inhibitor prior to surgical repair Operative unresponsive to medical therapy hemorrhage / perforation Zollinger-Ellison syndrome truly refractory cases consider an parietal cell vagotomy surgical approaches include: Billroth II (antrectomy with gastrojejunostomy) low recurrence but high rate of dumping syndrome Prognosis, Prevention, and Complications Hemorrhage, obstruction,perforation,intractable pain Gastric perforations have 10-40% mortality Duodenal perforations have 5-15% mortality