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Peptic Ulcer Disease Husam Barakat, MD American Board in Internal Medicine American board in Gastroenterology

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Page 1: Peptic Ulcer Disease - Doctor 2015 · Peptic Ulcer Disease Husam Barakat, MD American Board in Internal Medicine American board in Gastroenterology. INTRODUCTION • A peptic ulcer

PepticUlcerDiseaseHusamBarakat,MD

AmericanBoardinInternalMedicineAmericanboardinGastroenterology

Page 2: Peptic Ulcer Disease - Doctor 2015 · Peptic Ulcer Disease Husam Barakat, MD American Board in Internal Medicine American board in Gastroenterology. INTRODUCTION • A peptic ulcer

INTRODUCTION

• Apepticulcerisadefectinthegastricorduodenalmucosathatextendsthroughthemuscularis mucosaintothedeeperlayersofthewall

Page 3: Peptic Ulcer Disease - Doctor 2015 · Peptic Ulcer Disease Husam Barakat, MD American Board in Internal Medicine American board in Gastroenterology. INTRODUCTION • A peptic ulcer

CLINICALMANIFESTATIONS

• Dyspepsia—Upperabdominalpainordiscomfort• Asymptomatic— Approximately70percent ofpepticulcersareasymptomatic• Ulcercomplications- bleeding- gastricoutletobstruction- penetrationandfistulization- perforation

Page 4: Peptic Ulcer Disease - Doctor 2015 · Peptic Ulcer Disease Husam Barakat, MD American Board in Internal Medicine American board in Gastroenterology. INTRODUCTION • A peptic ulcer

BLEEDINGDU

Page 5: Peptic Ulcer Disease - Doctor 2015 · Peptic Ulcer Disease Husam Barakat, MD American Board in Internal Medicine American board in Gastroenterology. INTRODUCTION • A peptic ulcer

LABORATORYFINDINGS

• Mostpatientswithpepticulcershaveanormal completebloodcount.However,patientsmayhaveirondeficiencyanemiaduetogastrointestinalbloodloss

Page 6: Peptic Ulcer Disease - Doctor 2015 · Peptic Ulcer Disease Husam Barakat, MD American Board in Internal Medicine American board in Gastroenterology. INTRODUCTION • A peptic ulcer

DIAGNOSIS

• Upperendoscopy-

Unintentional weightloss

Progressivedysphagia

Odynophagia

Unexplainedirondeficiencyanemia

Persistentvomiting

Palpablemassorlymphadenopathy

Familyhistoryofuppergastrointestinalcancer

Page 7: Peptic Ulcer Disease - Doctor 2015 · Peptic Ulcer Disease Husam Barakat, MD American Board in Internal Medicine American board in Gastroenterology. INTRODUCTION • A peptic ulcer

DIAGNOSIS:GU

Page 8: Peptic Ulcer Disease - Doctor 2015 · Peptic Ulcer Disease Husam Barakat, MD American Board in Internal Medicine American board in Gastroenterology. INTRODUCTION • A peptic ulcer

DIAGNOSIS

• Imaging- CT- Barium

Page 9: Peptic Ulcer Disease - Doctor 2015 · Peptic Ulcer Disease Husam Barakat, MD American Board in Internal Medicine American board in Gastroenterology. INTRODUCTION • A peptic ulcer

GASTRICULCERONBARIUMMEAL

Page 10: Peptic Ulcer Disease - Doctor 2015 · Peptic Ulcer Disease Husam Barakat, MD American Board in Internal Medicine American board in Gastroenterology. INTRODUCTION • A peptic ulcer

PERFORATEDGU

Page 11: Peptic Ulcer Disease - Doctor 2015 · Peptic Ulcer Disease Husam Barakat, MD American Board in Internal Medicine American board in Gastroenterology. INTRODUCTION • A peptic ulcer

ESTABLISHINGTHEETIOLOGY

• TestforHelicobacterpylori- Biopsyureasetesting- Ureabreathtest- Stoolantigen• AssessmentofNSAIDuse• Other:smoking,malignancy,acidhypersecretion

Page 12: Peptic Ulcer Disease - Doctor 2015 · Peptic Ulcer Disease Husam Barakat, MD American Board in Internal Medicine American board in Gastroenterology. INTRODUCTION • A peptic ulcer

RAPIDUREASETEST

Page 13: Peptic Ulcer Disease - Doctor 2015 · Peptic Ulcer Disease Husam Barakat, MD American Board in Internal Medicine American board in Gastroenterology. INTRODUCTION • A peptic ulcer

DIFFERENTIALDIAGNOSIS

• Celiac• Gastricmalignancy• Chronicpancreatitis• Biliarydisease• Druginduceddyspepsia

Page 14: Peptic Ulcer Disease - Doctor 2015 · Peptic Ulcer Disease Husam Barakat, MD American Board in Internal Medicine American board in Gastroenterology. INTRODUCTION • A peptic ulcer

MANAGEMENT

• EradicationofHelicobacterpylori- Allpatientswithpepticulcersshouldbetested forinfectionwith H.pylori andtreated

- Inpatientstreatedfor H.pylori, eradication ofinfectionshouldbeconfirmed fourweeksafterthecompletionoftherapy

Page 15: Peptic Ulcer Disease - Doctor 2015 · Peptic Ulcer Disease Husam Barakat, MD American Board in Internal Medicine American board in Gastroenterology. INTRODUCTION • A peptic ulcer

MANAGEMENT

• Withdrawalofoffendingorcontributingfactors- Patientswithpepticulcersshouldbeadvisedtoavoidnonsteroidalanti-inflammatorydrugs(NSAIDs)

- Contributingfactorsshouldbeaddressedandtreated(eg,treatingmedicalcomorbidities,poornutritionalstatus,ischemia,smoking)

Page 16: Peptic Ulcer Disease - Doctor 2015 · Peptic Ulcer Disease Husam Barakat, MD American Board in Internal Medicine American board in Gastroenterology. INTRODUCTION • A peptic ulcer

MANAGEMENT

• Antisecretory therapy- H.pylori-positiveulcer:Inpatientswithuncomplicated duodenalulcers,theprotonpumpinhibitor(PPI),givenfor14days,alongwiththeantibioticregimentotreat H.pylori,isusuallyadequatetoinducehealing,andadditionalantisecretory therapyisnotneededaslongastheyareasymptomaticfollowingtherapy

- Inpatientswithcomplicated duodenalulcers,wesuggestantisecretory treatmentforfourtoeightweeksandinpatientswithgastriculcers,wesuggestantisecretory therapyfor8to12weeks

Page 17: Peptic Ulcer Disease - Doctor 2015 · Peptic Ulcer Disease Husam Barakat, MD American Board in Internal Medicine American board in Gastroenterology. INTRODUCTION • A peptic ulcer

MANAGEMENT

• Inpatientswithgastriculcers,wediscontinueantisecretory therapyonlyafterulcerhealinghasbeenconfirmedbyupperendoscopy• Cureof H.pylori infectionshouldbeconfirmedfourweeksaftercompletionoferadicationtherapy

Page 18: Peptic Ulcer Disease - Doctor 2015 · Peptic Ulcer Disease Husam Barakat, MD American Board in Internal Medicine American board in Gastroenterology. INTRODUCTION • A peptic ulcer

MANAGEMENT

• NSAID-inducedulcer- PatientswithNSAID-associatedulcersshouldbetreatedwithaPPIforaminimumofeightweeks

- InpatientswithpepticulcerswhoneedtoremainonNSAIDsor aspirin,maintenance antisecretory therapywithaPPIshouldbeconsideredtoreducetheriskofulcercomplicationsorrecurrence

Page 19: Peptic Ulcer Disease - Doctor 2015 · Peptic Ulcer Disease Husam Barakat, MD American Board in Internal Medicine American board in Gastroenterology. INTRODUCTION • A peptic ulcer

MANAGEMENT

• Non-H.pylori,non-NSAIDulcers- Inpatientswith H.pylori-negativeulcersthatarenotassociatedwithNSAIDuse,wesuggestPPItherapyforfourtoeightweeksbasedontheulcerlocation(gastricorduodenal)andthepresenceofcomplications

Page 20: Peptic Ulcer Disease - Doctor 2015 · Peptic Ulcer Disease Husam Barakat, MD American Board in Internal Medicine American board in Gastroenterology. INTRODUCTION • A peptic ulcer

MANAGEMENT

• ENDOSCOPYAFTERINITIALTHERAPY- Duodenalulcers—Giventhelowriskofmalignancyinpatientswithduodenalulcers,arepeatupperendoscopyisnotroutinelyrecommendedafterinitialtreatmentunlesssymptomspersistorrecur

Page 21: Peptic Ulcer Disease - Doctor 2015 · Peptic Ulcer Disease Husam Barakat, MD American Board in Internal Medicine American board in Gastroenterology. INTRODUCTION • A peptic ulcer

ENDOSCOPYAFTERINITIALMANAGEMENT• Gastriculcers:Wesuggestasurveillanceendoscopy(withbiopsiesoftheulcerifstillpresent)beperformedafter12weeksofantisecretory therapyinpatientswithgastriculcersandanyoneofthefollowing:

●Symptomsdespitemedicaltherapy.●Unclearetiology.●Giantulcer(>2cm).●Biopsiesnotperformedorinadequatesamplingontheindexupperendoscopy(totalof<4biopsiesobtainedfromfourquadrantsoftheulcerandadditionalbiopsiesoftheedgeswithjumboforcepsifthereareendoscopicfeaturesofamalignantgastriculcer).●Ulcerappearssuspiciousformalignancyonindexupperendoscopy(masslesion,elevatedirregularulcerborders,orabnormaladjacentmucosalfolds).●Initialendoscopywasperformedforbleeding.●Risksfactorsforgastriccancer(eg,age>50years, H.pylori,immigrantsfromaregionwithhighprevalenceofgastriccancer[eg,Japan,Korea,Taiwan,CostaRica],familyhistoryofgastriccancer,thepresenceofgastricatrophy,adenoma,dysplasia,intestinalmetaplasia).

Page 22: Peptic Ulcer Disease - Doctor 2015 · Peptic Ulcer Disease Husam Barakat, MD American Board in Internal Medicine American board in Gastroenterology. INTRODUCTION • A peptic ulcer

MANAGEMENT

• MAINTENANCETHERAPY• -Wecontinuemaintenanceantisecretory therapywithaprotonpumpinhibitorinthefollowinghigh-risksubgroupsofpatientswithpepticulcerdisease:

●Giant(>2cm)ulcerandage>50yearsormultipleco-morbidities●H.pylori-negative,nonsteroidalanti-inflammatorydrug(NSAID)-negativeulcerdisease●Refractorypepticulcer●Failuretoeradicate H.pylori●Frequentlyrecurrentpepticulcers(>2documentedrecurrencesayear)●ContinuedNSAIDuse

Page 23: Peptic Ulcer Disease - Doctor 2015 · Peptic Ulcer Disease Husam Barakat, MD American Board in Internal Medicine American board in Gastroenterology. INTRODUCTION • A peptic ulcer

COMPLICATIONSOFPUD

• GIbleed• Gastricoutletobstruction• Penetration• Fistulization• perforation

Page 24: Peptic Ulcer Disease - Doctor 2015 · Peptic Ulcer Disease Husam Barakat, MD American Board in Internal Medicine American board in Gastroenterology. INTRODUCTION • A peptic ulcer

TREATMENTDURINGPREGNANCYANDLACTATION

• Whenpepticulcerdiseaseisdiagnosedinawomanwhoispregnant,thefocusoftreatmentistypicallyacidsuppressionwithaprotonpumpinhibitor(PPI)• If H.pylori ispresent,antimicrobialtreatmentistypicallydeferreduntilafterdelivery• limiteddatawithomeprazoleandpantoprazolesuggestthatexcretioninmilkdoesoccurbutthelevelsarelow

Page 25: Peptic Ulcer Disease - Doctor 2015 · Peptic Ulcer Disease Husam Barakat, MD American Board in Internal Medicine American board in Gastroenterology. INTRODUCTION • A peptic ulcer

DISEASECOURSE

• Approximately60 percentofpepticulcershealspontaneously• witheradicationof H.pylori infection,ulcerhealingratesare>90percent• Evenwithcontinuedprotonpumpinhibitor(PPI)use,approximately5to30percent ofpepticulcersrecurwithinthefirstyearbasedonwhether H.pylori hasbeensuccessfullyeradicated• Approximately5to10percentofulcersarerefractorytoantisecretory therapywithaPPI• Theriskofcomplications inpatientswithchronicpepticulcerdiseaseis2to3percentperyear.

Page 26: Peptic Ulcer Disease - Doctor 2015 · Peptic Ulcer Disease Husam Barakat, MD American Board in Internal Medicine American board in Gastroenterology. INTRODUCTION • A peptic ulcer

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