Peptic Ulcer Disease - Gastrointestinal

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

Blood, Plasma, Serum	Reference Range
ALT	8-20 U/L
Amylase, serum	25-125 U/L
AST	8-20 U/L
Bilirubin, serum (adult) Total // Direct	0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca²⁺)	8.4-10.2 mg/dL
Cholesterol, serum	Rec: < 200 mg/dL
Cortisol, serum	0800 h: 5-23 μg/dL //1600 h: 3-15 μg/dL 2000 h: ≤ 50% of 0800 h
Creatine kinase, serum	Male: 25-90 U/L Female: 10-70 U/L
Creatinine, serum	0.6-1.2 mg/dL
Electrolytes, serum
Sodium (Na⁺)	136-145 mEq/L
Chloride (Cl^-)	95-105 mEq/L
Potassium (K⁺)	3.5-5.0 mEq/L
Bicarbonate (HCO₃^-)	22-28 mEq/L
Magnesium (Mg²⁺)	1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)
24-28 wks // 32-36 wks	30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks	40-220 ng/mL // 80-350 ng/mL
Ferritin, serum	Male: 15-200 ng/mL Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma	Male: 4-25 mIU/mL Female: premenopause: 4-30 mIU/mL midcycle peak: 10-90 mIU/mL postmenopause: 40-250
pH	7.35-7.45
PCO₂	33-45 mmHg
PO₂	75-105 mmHg
Glucose, serum	Fasting: 70-110 mg/dL 2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation	Fasting: <5 ng/mL Provocative stimuli: > 7ng/mL
Immunoglobulins, serum
IgA	76-390 mg/dL
IgE	0-380 IU/mL
IgG	650-1500 mg/dL
IgM	40-345 mg/dL
Iron	50-170 μg/dL
Lactate dehydrogenase, serum	45-90 U/L
Luteinizing hormone, serum/plasma	Male: 6-23 mIU/mL Female: follicular phase: 5-30 mIU/mL midcycle: 75-150 mIU/mL postmenopause 30-200 mIU/mL
Osmolality, serum	275-295 mOsmol/kd H₂O
Parathyroid hormone, serume, N-terminal	230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C)	20-70 U/L
Phosphorus (inorganic), serum	3.0-4.5 mg/dL
Prolactin, serum (hPRL)	< 20 ng/mL
Proteins, serum

Hematologic	Reference Range
Bleeding time	2-7 minutes
Erythrocyte count	Male: 4.3-5.9 million/mm³ Female: 3.5-5.5 million mm³
Erythrocyte sedimentation rate (Westergren)	Male: 0-15 mm/h Female: 0-20 mm/h
Hematocrit	Male: 41%-53% Female: 36%-46%
Hemoglobin A1c	≤ 6 %
Hemoglobin, blood	Male: 13.5-17.5 g/dL Female: 12.0-16.0 g/dL
Hemoglobin, plasma	1-4 mg/dL
Leukocyte count and differential
Leukocyte count	4,500-11,000/mm³
Segmented neutrophils	54%-62%
Bands	3%-5%
Eosinophils	1%-3%
Basophils	0%-0.75%
Lymphocytes	25%-33%
Monocytes	3%-7%
Mean corpuscular hemoglobin	25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration	31%-36% Hb/cell
Mean corpuscular volume	80-100 μm³
Partial thromboplastin time (activated)	25-40 seconds
Platelet count	150,000-400,000/mm³
Prothrombin time	11-15 seconds
Reticulocyte count	0.5%-1.5% of red cells
Thrombin time	< 2 seconds deviation from control
Volume
Plasma	Male: 25-43 mL/kg Female: 28-45 mL/kg
Red cell	Male: 20-36 mL/kg Female: 19-31 mL/kg

Cerebrospinal Fluid	Reference Range
Cell count	0-5/mm³
Chloride	118-132 mEq/L
Gamma globulin	3%-12% total proteins
Glucose	40-70 mg/dL
Pressure	70-180 mm H₂O
Proteins, total	< 40 mg/dL

Sweat	Reference Range
Chloride	0-35 mmol/L
Urine
Calcium	100-300 mg/24 h
Chloride	Varies with intake
Creatinine clearance	Male: 97-137 mL/min Female: 88-128 mL/min
Estriol, total (in pregnancy)
30 wks	6-18 mg/24 h
35 wks	9-28 mg/24 h
40 wks	13-42 mg/24 h
17-Hydroxycorticosteroids	Male: 3.0-10.0 mg/24 h Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total	Male: 8-20 mg/24 h Female: 6-15 mg/24 h
Osmolality	50-1400 mOsmol/kg H₂O
Oxalate	8-40 μg/mL
Potassium	Varies with diet
Proteins, total	< 150 mg/24 h
Sodium	Varies with diet
Uric acid	Varies with diet
Body Mass Index (BMI)	Adult: 19-25 kg/m²