Peptic Ulcer Disease

Katarzyna Lalicata, MSN, FNP-C, FNP-BC
Thursday March 01, 2018
Peptic ulcer disease can be classified into duodenal and gastric ulcers. Alterations in the mucosa occur when the normal defense mechanisms of the gastric or duodenal mucosa are impaired or overwhelmed by factors such as acid and pepsin.1 

In the United States, lifetime risk of duodenal and gastric ulcers is about 10%. Although more prevalent in the duodenum, gastric ulcers have become more common, secondary to use of low-dose aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs). NSAID-induced ulcers are especially dangerous within 90 days of use for patients who take other medications, such as anticoagulants, aspirin, and corticosteroids, as well as for those over age 60.1 

Peptic ulcer disease has been linked to NSAID use and Helicobacter pylori infection, as well as other conditions, such as cirrhosis, cytomegalovirus, kidney disease, medications such as alendronate sodium (Fosamax), and Zollinger-Ellison syndrome. H pylori–related gastric ulcers are associated with decreased acid secretion and, theoretically, chronic inflammation that affects the gastric mucosal defense mechanisms. NSAIDs inhibit prostaglandins, whereas aspirin has an effect on platelet aggregation, increasing the risk of complications associated with ulcers.1 

CASE STUDY

John is a 66-year-old man who works full time in risk management. Due to company cutbacks, he has been assigned more work with fewer staff members to assist him, and clients have become angry. This has caused more stress for John. In his personal life, he has had to take out a second mortgage on his home, and he worries about work and paying the bills. John started noticing a gnawing feeling in his upper abdominal area and a burning sensation during the day, which went away immediately after he ate a meal. To manage the pain, he started taking OTC ibuprofen as directed on the package, but then he increased it to the maximum amount advised. Because he could no longer deal with the discomfort, John decided to make an appointment with his primary care provider. He reported no chills, fever, rash, recent illness, or weight changes. John said he does not smoke or drink alcohol. 

Discussion Question: What additional information would you want to know about John’s history and presentation?

Answer: It would be imperative to ask him if he has had red flag symptoms such as bleeding, early satiety, painful or trouble swallowing, or vomiting.2 Reviewing any history of chest pain, frequent indigestion, palpitations, pressure, and shortness of breath can further assist in determining an underlying cause. John’s history and family history of cardiac disease and cancer, particularly gastric cancer, also should be reviewed. It is also important to ask him if he has used NSAIDs continuously in the past for other complaints, alone or in combination with aspirin or other cyclooxygenase-2 (COX-2) inhibitors. 

Discussion Question: What findings during the physical exam would cause concern, should John exhibit them?


Answer: Alarming findings include a severely tender, boardlike abdomen, which can indicate perforation. Orthostasis and tachycardia can be associated with active gastrointestinal (GI) blood loss secondary to dehydration.

Discussion Question: What tests can aid in making the diagnosis of a gastric ulcer?


Answer: Testing for anemia, including a complete blood count and iron panel, can help the provider determine if an endoscopy is needed to evaluate blood loss associated with ulcers. Liver function tests, amylase, and lipase can aid in evaluating differential diagnosis for pain, including biliary colic and pancreatitis.4 Testing for H Pylori can be done through an upper GI series, combined with a fecal antigen assay or urea breath testing. To prevent false negative results, ensure that the patient has not taken any proton pump inhibitors (PPIs), such as omeprazole or pantoprazole; if he has, withholding medication 7 to 14 days prior to H pylori testing is essential.1

Given that gastric ulcers, unlike duodenal ulcers, can be malignant, it is recommended that patients have a biopsy upon initial discovery.3 An endoscopy would be indicated if John had any alarming findings or occult bleeding.4 

Discussion Question: What treatment options are available to treat his gastric ulcer?


Answer: Treatment involves eradicating H pylori, eliminating offending agents, and adding an antisecretory and mucosal protective agent.

The combined use of 2 or 3 antibiotics with either bismuth or a PPI is recommended to eradicate H pylori and decrease the chance of developing bacterial resistance.1 Consideration should be taken for resistance to antibiotics based on the treatment region.1 American College of Gastroenterology recommendations include 10 to 14 days of quadruple therapy of bismuth, a PPI, tetracycline, and nitroimidazole, especially in patients with allergies to penicillin or previous exposure to macrolides.2 Alternatives include 10 to 14 days quadruple therapy of a PPI, clarithromycin, amoxicillin, and a nitroimidazole.2

A triple therapy treatment option—clarithromycin, a PPI, and amoxicillin or metronidazole—is indicated for patients with no history of macrolide exposure in areas where resistance to clarithromycin is low.2 Suggested options also include 5 to 7 days of sequential combination therapy of a PPI and amoxicillin, followed by 5 to 7 days of clarithromycin, a PPI, and nitroimidazole; 7 days of a PPI and amoxicillin, followed by 7 days of a PPI, amoxicillin, clarithromycin, and nitroimidazole; and 10 to 14 days of levofloxacin, a PPI, and amoxicillin.2 Fluoroquinolone sequential therapy (amoxicillin and a PPI), followed by 5 to 7 days of a PPI, fluoroquinolone, and nitroimidazole, may also be used for first-line therapy.2 Quadruple therapy, though more complex, is more effective compared with the other regimens.1 

It is important to treat the active ulcer, as well as prevent recurrence. If John has an ulcer that is larger than 1 cm, an antisecretory agent to aid healing may be considered for 4 to 6 weeks after antibi- otic treatment ends.2 If endoscopy findings show an ulcer that is less than 1 cm and dyspepsia symptoms have resolved, no antisecretory agents are needed. 

Antisecretory agents include receptor antagonists and PPIs. H2-receptor antagonists, such as famotidine and ranitidine, are effective, but PPIs are preferred, although they are associated with a small decrease in absorption of B12, calcium, and iron. Antacids, bismuth, and misoprostol can aid in healing but are not first-line therapy for treating active ulcers.1 

John should stop taking NSAIDs and be offered an alternative medication to manage pain. 

Discussion Question: What are the follow-up recommendations?

Answer: To confirm healing of a gastric ulcer and evaluate for gastric cancer following the initial diagnosis, an endoscopy is recommended 6 to 12 weeks following initial therapy. John should also be educated on the importance of avoiding alcohol, COX-2 inhibitors, NSAIDs, and smoking.3 


Katarzyna LaLicata, MSN, FNP-C, FNP-BC,
is a nurse practitioner
 at Minute Clinic and an associate clinical assistant professor at National University in San Diego, California. 


References

1. McQuaid KR. Gastrointestinal disorders. In: Papadakis MA, McPhee SJ, Rabow MW, eds. Current Medical Diagnosis & Treatment. 53rd ed. New York, NY: McGraw Hill Education; 2014:592-600.
2. Ananda BS. Peptic ulcer disease. Medscape website. emedicine.medscape.com/arti- cle/181753-overview. Updated January 29, 2017. Accessed December 30, 2017.
3. Hasler WL, Owyang C. Approach to the patient with gastrointestinal disease. In: Longo D, Fauci A, Kasper D, Hauser S, Jameson J, eds. Harrison’s Principles of Internal Medicine. 18th ed. New York, NY: The McGraw-Hill Companies, Inc; 2012:2438-2459.
4. Kiefer MM, Chong CR. Peptic ulcer disease. In: Pocket Primary Care. Philadelphia, PA: Lipincott Williams & Wilkins, a Wolters Kluwer business; 2014:5-24–5-25. 









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