Peptic ulcer disease and Helicobacter pylori

1/ Definition of peptic ulcer disease

  • Ulceration of the oesophageal, gastric or duodenal mucosa

2/ 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

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3/ Peptic ulcer disease Epidemiology

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

4/ Helicobacter Pylori Infections

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

5/ Causes of peptic ulcer disease

1- 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)
  • See ‘complications of H.Pylori’ section below for full list of H.Pylori associations

2- Drugs

  • Aspirin
  • NSAIDs
  • Steroids


4- Alcohol

5- Stress

  • Curling’s ulcer (burns – sloughing of mucosa due to plasma loss)
  • Cushing’s ulcer (raised intracranial pressure – changes to vagal tone)

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6- Acid hypersecretion

  • Zollinger-Ellison – gastrin-secreting tumour (gastrinoma)
    • Responsible for 1/1000. Multiple ulcers.
    • Treat with high-dose PPI (or curative resection)
  • Small bowel resection (loss of negative feedback on acid secretion)
  • Systemic mastocytosis (increase histamine production)

7- Abnormal gastric emptying

  • Too fast can give duodenal ulcers
  • Too slow can cause gastric ulcers and succussion splash

6/ Sign and Syptoms 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
    • Haematemesis or melaena
    • Anterior duodenal ulcers tend to bleed, posterior ulcers are more likely to perforate than anterior ulcers
    • ALARM symptoms (see dyspepsia section)
  • Signs:

    • Sometimes epigastric tenderness
    • Succussion splash if gastric emptying delayed

7/ 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.
  • Trial of full-dose proton pump inhibitor (PPI) for 4-8 weeks for patients with GORD symptoms.
  • Offer H2 blocking therapy therapy (e.g. Ranitidine 150mg once to twice daily) if inadequate response to PPI.
  • Test for Helicobacter pylori (H. pylori) if symptoms persist (see below for testing methods):
    • 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.
  • Upper GI endoscopy if symptoms persist despite above
  • Urgent (within 2 weeks) upper GI endoscopy if:
    • ALARMS symptoms present
    • Age < 55
      • High risk i.e. previous gastric surgery; FHx gastric malignancy

8/ Complications of PUB and H. pylori

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

9/ Prognosis

  • Approximately 2% recurrence rate
    • Smoking, ETOH, NSAIDs increases recurrence rate (especially gastric ulcers)

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