Updated: 12/23/2018

Peptic Ulcer Disease

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  • 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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Questions (5)
Lab Values
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  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
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
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(M1.GI.4) A 41-year-old male who takes NSAIDs regularly for his chronic back pain develops severe abdominal pain worse with eating. Upper endoscopy is performed and the medical student asks the supervising physician how the histological differentiation between a gastric ulcer and erosion is made. Which of the following layers of the gastric mucosa MUST be breached for a lesion to be considered an ulcer? Review Topic

QID: 101061
1

Epithelium

4%

(6/160)

2

Epithelium, lamina propria

7%

(11/160)

3

Epithelium, lamina propria, muscularis mucosa

21%

(34/160)

4

Epithelium, lamina propria, muscularis mucosa, and submucosa

64%

(102/160)

5

Epithelium, lamina propria, muscularis mucosa, submucosa, and adventitia

2%

(3/160)

M1

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

(M1.GI.20) A 52-year-old Caucasian male presents to your office complaining of black, tarry stool. Which of the following possible causes of this patient's presentation is LEAST associated with the development of carcinoma? Review Topic

QID: 101077
1

Barrett's esophagus

9%

(2/22)

2

H. pylori infection

5%

(1/22)

3

Adenomatous polyp

18%

(4/22)

4

Gastric ulcer

5%

(1/22)

5

Duodenal ulcer

64%

(14/22)

M1

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PREFERRED RESPONSE 5

(M1.GI.76) A 34-year-old Caucasian male presents with symptoms consistent with peptic ulcer disease. The physician suspects H. pylori infection and decides to perform a biopsy. By looking at Figure A, which site corresponds to the most likely location of the bacterium? Review Topic

QID: 101133
FIGURES:
1

A

0%

(0/26)

2

B

23%

(6/26)

3

C

65%

(17/26)

4

D

0%

(0/26)

5

E

8%

(2/26)

M1

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PREFERRED RESPONSE 3
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