Peptic ulcer disease and Helicobacter pylori

Definition of peptic ulcer disease

• Ulceration of the oesophageal, gastric or duodenal mucosa

Definition of Helicobacter pylori (H.pylori)

• Gram-negative bacterium found in the stomach and associated with the development of peptic ulcer disease and gastric cancer

Epidemiology of peptic ulcer disease

• 1-2/1000 per year. Previously much more common in men, now roughly equal.
• Duodenal ulcers 4 x more common than gastric ulcers

Epidemiology of H.pylori

• Prevalence approximately 30% young adults
• Much higher in older people

Causes of peptic ulcer disease

• H. Pylori (approximately 80%)
  • Risk factor for:
    • Peptic ulcer disease
    • Gastric cancer (six-fold increased risk)
    • MALT lymphoma (which may regress if H.Pylori is treated)
    • Drugs
      • Aspirin
      • NSAIDs
      • Steroids
      • Curling’s ulcer (burns – sloughing of mucosa due to plasma loss)
      • Cushing’s ulcer (raised intracranial pressure – changes to vagal tone)
      • Zollinger-Ellison – gastrin-secreting tumour (gastrinoma)
        • Responsible for 1/1000. Multiple ulcers.
        • Treat with high-dose PPI (or curative resection)
        • Too fast can give duodenal ulcers
        • Too slow can cause gastric ulcers and succussion splash

        Presentations of peptic ulcer disease

        • Symptoms:
          • Heartburn
          • Dyspepsia (burping, distension, bloating) – either before or after meals
          • Symptoms relieved by antacids
          • Pain
            • Epigastric
            • Posterior in a posterior ulcer
            • Sometimes epigastric tenderness
            • Succussion splash if gastric emptying delayed

            Differential diagnosis of peptic ulcer disease (see dyspepsia section)

            • Oesophagitis/Gastritis
              • Alcohol; NSAIDs; Stress
              • Hiatus hernia
              • Barrett’s oesophagus

              Initial management of peptic ulcer disease and H. pylori infection

              • Lifestyle advice
                • Weight loss; smoking cessation; avoid precipitants; raise the head of the bed; don’t eat late at night
                • Stop NSAIDs / bisphosphonates / steroids
                • Use of antacids (eg. Gaviscon, Peptac) PRN.
                • Treat H. pylori if positive or if endoscopic evidence of PUD
                • Eradication therapy
                  • Amoxicillin 1g twice daily and Clarithromycin 500mg twice daily plus full-dose PPI for 7 days.
                  • If allergic to penicillin then substitute Clarithromycin 250mg and Metronidazole 400mg both twice daily.
                  • ALARMS symptoms present
                  • Age < 55
                    • High risk i.e. previous gastric surgery; FHx gastric malignancy

                    Further management of peptic ulcer disease

                    • If patients present with an acute upper GI bleed secondary to PUD then manage as per any other GI bleed (see upper GI bleed section)
                    • H.pylori testing:
                      • Allow a 2 week washout period after stopping the PPI before testing for H.Pylori
                      • Options:
                        • C13-Urea breath test is the best first line test
                        • Stool antigen test
                          • Both have sensitivity and specificity of approximately 95%
                          • Sens 95%, spec only 85%
                          • Cannot confirm eradication with it and persistent response

                          Complications of peptic ulcer disease and H. pylori

                          • Haemorrhage:
                            • Controlled endoscopically
                            • Adrenaline, diathermy, laser coagulation, heat probe.
                            • Bleeding ulcer base can be undersewn by surgeons
                            • Conservative approach (NBM, NG, IV antibiotics) can prevent surgery in up to 50%, if no generalised peritonitis present
                            • Laparoscopic repair of hole
                            • Balloon dilatation + PPIs
                            • If ineffective, drainage procedure (e.g. pyloroplasty)
                            • B-cell
                            • Metastases are rare
                            • Associated with paraproteins and pseudohyponatraemia
                            • H.Pylori eradication leads to regression in 80%
                            • VacA and CagA strains of H pylori appear to be associated with an increased risk of gastric cancer

                            Prognosis of peptic ulcer disease

                            • Good, if underlying cause addressed.
                              • Approximately 2% recurrence rate
                              • Smoking, ETOH, NSAIDs increases recurrence rate (especially gastric ulcers)

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