Topic : PUD

**Commonly presented with epigastric pain, heartburn, indigestion

Ddx
- PUD (DU/GU)
- Gastritis
- Oesophagitis
- GORD
- Pancreatitis
- Cholecystitis
- Gastric neoplasia
- ACS
- AAA

HPC
- Would you mind to describe what do you mean by having
indigestion/dyspepsia?
- Onset?
- Have you had this before?
- Epigastric pain ask SRTCOPDSARA
- Aggravating factors: food (GU), occurs in early morning (DU)
- Relieving factors: Food, milk (DU), relieved by antacids (GU)
- Associated symptoms:
Nausea
Vomiting
Haematemesis? coffee ground vomiting?
Anorexia (any loss of appetite?)
Early satiety (do you feel full after eating a small amount of food?)
Weight loss
Difficulty in swallowing? (dysphagia)
Any pain on swallowing? (odynophagia)
Heartburn
Bitter taste in mouth
Bloatedness
Change in bowel movement?
Blood in your back passage? (malaena)
SOB (anaemia)
fatigue (anaemia)

RF
- Hx of PUD
- Hx of H.pylori infection/bacterial infection in the stomach?
- Smoking
- Alcohol
- Medications especially NSAIDs, aspirin, AC, steroids, alendronate?
 - Stresses
- Medical problem related to high gastric acid secretion in the stomach?
(Zollinger-Ellison syndrome)

Physical exam
- Epigastric tenderness
- Epigastric masses
- Supraclavicular nodes (virchows nodes-gastric adenocarcinoma)
- Guarding, rigidity, rebound tenderness (perforated PUD)

Investigations
1. Bloods FBC, U&E,CRP,ESR,LFT,Amylase, troponin(rule out other
causes), coag profile, group and x-match 2-4units , fasting
serum gastrin if recurrent PUD with negative CLOtest and no
hx of NSAIDs

2. Urinary amylase rule out pancreatitis

3. Erect CXR suspect perforated PUD

4. Upper GI endoscopy with biopsy urease test/CLOtest (1st line) +/-

gastric antral mucosal histology (to exclude gastric malignancy) +/-
bacterial culture (less commonly done)

5. Barium meal (if gastroscopy is CI) accumulation of barium at

ulcerated area

6. Urea breath test (13C breath test) high sensitivity, specificity and
noninvasive but expensive.

7. Stool antigen assay

Management
(depends on age (>55yo), ALARMS symptoms, severity of presentation ie emergency
with perforated PUD)

1. Conservative
- Reducing RF by discontinue NSAIDs or other medications, avoid
alcohol, stop smoking.
- Antacids magnesium trisillicate 10ml TDS PO

2. H.pylori eradicate with triple therapy /quadruple therapy

- Lansoprazole 30mg bd/ Omeprazole 20mg bd + amoxicillin 1g bd +

clarithromycin 500mg bd x 2/52 (followed by OD for 4-6/52)
Or,
 - 1 PPI + Ranitidine bismuth citrate 400mg bd + 2 abx ( clarithromycin
resistance >15%)
- review in 4 weeks. if no improvement do UBT to check for eradication
of H.pylori. Repeat triple therapy of positive H.pylori (not more than
twice)
- consider upper GI endoscopy if no improvement and ve for H.pylori

3. Non-H.pylori PPI + H2 blocker (ranitidine/cimetidine) x 4-6/52

4. Bleeding-
- Assess and maintain ABC, vitals, hx and exam
- calculate Blatchford score (0 discharge and consider opd
endoscopy, =/> 1 admit and do inpatient endoscopy)
- 2 large bore iv cannulae, bloods (fbc,u&e.lft,coag,grp and xmatch)
- iv normal saline
- consider blood transfusion if Hb <7g/dL or CAD
- NPO
- Stop NSAIDs
- IV omeprazole initial bolus 80mg f/by continuous infusion at rate
of 8mg/hr for 72 hours
- Endoscopy
- If active bleeding, consider endoscopy therapy with adrenaline
injection/thermo-coagulation/haemoclipping/haemostatic spray .
- Surgical intervention :
DU- Duodenotomy and over sewing of the artery
GU- biosy and oversewing of artery or wedge resection of
ulcer if patient is unstable
- antrectomy and vagotomy if patient is stable

**Indications for surgery in haemorrhagic PUD:

- Repeated episodes of bleeding despite of medical treatment and
endoscopic therapy
- Haemodynamic instability
- Ongoing transfusion
- More than one successful OGD

Blatchford Score: pre endoscopy

Blood Urea (mmol/L)
< 6.5 0
6.5 7.9 2
8.0 9.9 3
10 24.9 4
25 6
Hemoglobin (g/dL) (men)
13 0
12 12.9 1
10 11.9 3
< 10 6
Hemoglobin (g/dL) (women)
12 0
10 11.9 1
< 10 6

Systolic Blood Pressure (mm Hg)

110 0
100 - 109 1
90 - 99 2
< 90 3

Heart Rate 100 (beats/min) 1

Melena at presentation 1
Syncope at presentation 2
Hepatic Disease 2
Cardiac Failure 2

Rockall Score: post endoscopy

Age
< 60 0
60 - 79 1
80 2

Shock
No Shock 0
Heart Rate < 100
Systolic Blood Pressure 100
Tachycardia 1
Heart Rate 100
Systolic Blood Pressure 100
Hypotension 2
Systolic Blood Pressure < 100

Co-morbidity
No Major Co-morbidity 0
Ischaemic Heart Disease 2
Cardiac Failure
Renal Failure 3
Liver Failure
Disseminated Malignancy

Endoscopic Diagnosis
Mallory Weiss Tear 0
No Lesion identified
No stigmata of recent
hemorrhage
All other diagnosis 1
Upper GI Tract Malignancy 2

Endoscopy Stigmata of recent

Hemorrhage
None 0
Blood in Upper GI Tract 2
Adherent clot
Visible blood vessel
Spurting blood vessel

5. Perforated PUD
- ABC
- 2 large bore IV cannulae
- IV normal saline
- IV analgesia
- NG tube
- Surgical repair of perforation + oversewn of ulcer and secured
with a plug of omentum.

6. Gastric outlet obstruction -

- Aggressive initial resuscitation drip and suck
- NPO
- NGT
- 2 wide bore iv cannulae
- iv fluids and correct e abn (hypokalaemic metabolic alkalosis)
- iv PPI
- obstruction persists more than 7 days, consider sugery
Gastro-enterostomy
truncal vagotomy
pyloroplasty
partial gastrectomy

**NOTES
1. Complications of PUD bleeding, perforation, gastric outlet obs

2. Bleeding erosion of DU through post. wall of duodenum into

gastroduodenal artery. Patient maybe shock / massive hematemesis
ground coffee vomiting/malaena at presentation

3. Perforation DU perf twice more common than GU perf. Anterior surface

of duodenal bulb just beyond pylorus. Severe abd pain and peritonitis.

4. Gastric outlet obs :

- pylorus/prepyloric area.
- ulcer healing with fibrosis leads to stricture and pyloric stenosis
- presents with episodic, projectile vomiting unrelated to eating,
dehydrated and undernourished.
- Succession splash on auscultation (sloshing sound while moving
patient on auscultation)
- Hypochloraemic alkalosis
- PFA hugely dilated stomach

5. GU takes longer to heal than DU

6. PPI is more effective to heal ulcer than H2 blocker