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Peptic Ulcer Disease

Peptic Ulcer Disease. Lerma , Daniel Joseph M. Peptic Ulcer Disease. Ulcer - disruption of the mucosal integrity of the stomach and/or duodenum leading to a local defect or excavation due to active inflammation; breaks in the mucosal surface >5 mm in size, with depth to the submucosa .

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Peptic Ulcer Disease

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  1. Peptic Ulcer Disease Lerma, Daniel Joseph M.

  2. Peptic Ulcer Disease • Ulcer - disruption of the mucosal integrity of the stomach and/or duodenum leading to a local defect or excavation due to active inflammation; breaks in the mucosal surface >5 mm in size, with depth to the submucosa. • Burning epigastric pain exacerbated by fasting and improved with meals is a symptom complex associated with PUD

  3. Epidemiology/Incidence • Duodenal Ulcer • occur in 6–15% of the Western population • incidence of DUs declined steadily from 1960 to 1980 and has remained stable since then • death rates, need for surgery, and physician visits have decreased by >50% over the past 30 years; reason for the reduction in the frequency of DUs is likely related to the decreasing frequency of Helicobacter pylori. • Gastric Ulcer • tend to occur later in life than duodenal lesions, peak incidence in 6th decade of life • More than half occur in males; higher likelihood of being “silent” and presenting only after a complication develops

  4. Pathology • Duodenal Ulcer • occur first portion of duodenum (>95%), with ~90% located within 3 cm of the pylorus. • usually 1 cm in diameter; can reach 3–6 cm (giant ulcer). • sharply demarcated, sometimesreaching the muscularispropria; base of the ulcer often consists of a zone of eosinophilic necrosis with surrounding fibrosis. Malignant DUs are extremely rare. • Gastric Ulcer • In contrast to DUs, GUs can represent a malignancy • Benign GUs  often found distal to the junction between the antrum and the acid secretory mucosa; quite rare in the gastric fundus and are histologically similar to DUs. • Benign GUs associated with H. pylori are also associated with antral gastritis

  5. UGI Bleeding due to PUD • Peptic ulcers are the most common cause of UGIB (50% of cases) • increasing proportion is due to NSAIDs, with the prevalence of H. pylori decreasing. • Ulcer characteristics at endoscopy provide important prognostic information. • 1/3 of patients with active bleeding or a nonbleeding visible vessel have further bleeding that requires urgent surgery if they are treated conservatively.* • In contrast, patients with clean-based ulcers have rates of recurrent bleeding approaching zero. **

  6. One-third of patients with a bleeding ulcer will rebleed within the next 1–2 years. Prevention of recurrent bleeding focuses on the three main factors in ulcer pathogenesis • H. pylori eradication • NSAIDs should be discontinued if a bleeding ulcer develops, and if NSAIDs must be continued, initial treatment should be with a PPI. Long-term preventive strategies to decrease NSAID-associated ulcers include use of a cyclooxygenase 2 (COX-2) selective inhibitor (coxib) or addition of GI co-therapy to a traditional NSAID • Patients with bleeding ulcers unrelated to H. pylori or NSAIDs should remain on full-dose antisecretory therapy indefinitely. Peptic ulcers are discussed in Chap. 287.

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