Peptic Ulcer Disease – BC Guideline

Dyspepsia is a symptom

1 In a patient presenting with dyspepsia, include cardiovascular disease in the differential diagnosis.

DDx:

• Cardiac: CAD/MI/PE/Pericarditis/Myocarditis/Aortic dissection/Tamponade
• Boerhaves
• Hepatobiliary, colonic, Celiac, Achalasia, MSK, esophageal stricture / scleroderma
• Dyspepsia: GERD, gastric cancer (Zollinger-Ellison), esophageal cancer, pancreatic cancer, gallstone pancreatitis

2 Attempt to differentiate, by history and physical examination, between conditions presenting with dyspepsia (e.g., gastroesophageal reflux disease, gastritis, ulcer, cancer), as plans for investigation and management may be very different.

3 In a patient presenting with dyspepsia, ask about and examine the patient for worrisome signs/symptoms (e.g., gastrointestinal bleeding, weight loss, dysphagia).

Despepsia Alarming symptoms – VW BAAAD

• Vomiting
• Wt loss – unexplained, night sweat, fever, chills (constitutional symptoms)
• Blood – Hematemesis or melena
• Age > 50
• Anemia
• Abdominal mass
• Dysphagia, odynophagia

Lifestyle Modifications:

PUD

1. Avoidance of foods that aggravate dyspepsia: alcohol, caffeine, irritating food
2. Smaller meals,
3. smoking cessation,
4. d/c NSAIDs if possible

GERD

1. weight control
2. reduce alcohol/tobacco/caffeine
3. avoid lying down within 2 hrs of eating and elevate head of bed
4. avoid food triggers such as spices, peppermint, chocolate, citrus juice
5. over the counter antacid or H2 receptor blocker, e.g. ranitidine, if not already tried.

Risk Factors – GUD

• H Pylori infection (GUD, but not GERD)
• NSAID, bisphosphonate, or steroid use
• Smoking, EtOH (gastritis)
• Radiation damage
• Crohn’s dz

Risk Factors – GERD

• Increased intraabdominal pressure, pregnancy, obesity
• Medications decrease LES pressure: CCB, anticholingergics, theophylline, nitrate, sildenafil

PUD – Empiric versus Test-and-Treat strategy

1. Empiric tx strategy:
   1. PPI OD or H2RA BID, x 4-8 wk
   2. reassess, if still symptomatic switch PPI, or BID PPI
   3. if still symptomatic, breath test for H Pylori (Must be off PPi for min of 2 weeks), or prompt endoscopy
2. Test-and-treat strategy:
   1. test for H pylori,
   2. tx with triple therapy if positive
3. Endoscopy if
   1.  >50 with new symptoms
   2. Alarm features (see above)
   3. Failed repeated trial of therapy (see empiric tx strategy)

(however 10% of DU and 30% of GU may be H pylori negative)

Triple therapy regimes: