Peptic Ulcer Disease and Gastritis - CRASH! Medical Review Series

This update provides information on peptic ulcer disease and gastritis, focusing on the similarities in diagnosis and treatment over the last five years. The lecture aims to address these conditions, which are significant causes of epigastric pain.

Causes of Epigastric Pain The number one cause of epigastric pain is GERD, often mistaken for chest pain and can be misdiagnosed as a heart attack. Other causes include peptic ulcer disease, gastritis, pancreatitis (especially in alcoholics), esophagitis, cholecystitis, choledocholithiasis, cholangitis diverticulitis. Cancer should also be considered with alarm signs like weight loss and anemia fatigue.

Peptic Ulcer Disease When the cause is known it's usually idiopathic or due to NSAID use or H.pylori infection. Gastric ulcers may occur during eating while duodenal ulcers tend to be relieved by eating but symptoms alone are not reliable for differentiation. Ulcers can also occur as part of larger diseases such as Crohn's disease and Zollinger-Ellison syndrome.

When dealing with patients presenting GI symptoms, it's crucial to watch out for alarm symptoms such as weight loss, anemia, positive stools (Melena), hematemesis, early satiety, dysphagia or age over 45. These could indicate a more urgent situation requiring endoscopy to rule out cancer.

When suspecting an ulcer, testing for H. pylori is crucial and commonly done using serology, gastric biopsy, stool antigen checks, or urea breath test. Serology is the most sensitive as it always tests positive in case of infection and remains positive even after treatment. Gastric biopsy provides more specific results but requires endoscopy; stool antigen checks are useful to check response to therapy; urea breath test may be less preferred due to discontinuation of proton pump inhibitors.

Symptoms of Peptic Ulcer Disease Peptic ulcer disease can cause postprandial gastric pain, pain with eating, and nighttime awakening. Patients may describe it as heartburn unresponsive to antacids or experience alarm symptoms such as frequent NSAID use.

Diagnosis and Treatment of Peptic Ulcer Disease For patients without alarm symptoms, H. pylori serology should be the first test followed by CBC for anemia, CMP for liver enzymes check, B12 and MMA tests. An occult stool blood test is also recommended if bleeding ulcer is suspected. Endoscopy should be considered for patients with alarm symptoms like active bleed or weight loss. Triple therapy (PPI + clarithromycin + amoxicillin) is indicated for H.pylori positive peptic ulcers; PPI alone if H.pylori negative.

If the patient doesn't respond to treatment for an H. pylori ulcer, consider endoscopy and changing the antibiotic regimen. An alternative regimen includes metronidazole with tetracycline and a proton pump inhibitor; bismuth can also be added for quadruple therapy.

Peptic ulcer disease can lead to complications such as perforation, which presents with sudden worsening abdominal pain and peritoneal-like symptoms. Look for domino distension, fever, and shock as signs of a surgical emergency. Immediate surgery is the treatment for perforated ulcers. Gastric adenocarcinoma and MALT lymphoma can result from H.pylori infection; both may masquerade as one another but have different responses to therapy.

Perforated Peptic Ulcer The treatment for a perforated peptic ulcer is surgical. On an abdominal film, the diaphragmatic air can be seen pushing up into the chest cavity. Chest x-ray or abdominal x-ray can reveal this condition.

Gastritis and Its Diagnosis Gastritis is the third most commonly diagnosed cause of epigastric pain, characterized by generalized inflammation of stomach tissue without ulcers. It presents similar symptoms to peptic ulcer disease and may cause bleeding leading to hematemesis or melena. Alcohol and tobacco alone can cause gastritis, unlike ulcers which they worsen.

Gastritis caused by low B12 levels, often due to malnutrition or alcoholism. Symptoms include epigastric pain and macrocytic anemia with fatigue and pallor. Diagnosis based on low B12 levels, high MMA levels, and characteristic pattern in blood smear.

Pernicious Anemia: Cause and Symptoms Pernicious anemia is caused by autoimmune gastritis, which attacks the cells responsible for absorbing B12. This results in a deficiency of B12 due to lack of intrinsic factor production in the stomach. Family history may be present but not always. Symptoms include epigastric pain, fatigue, reduced peripheral vibratory sensation, and macrocytic anemia.

Diagnosis and Treatment Diagnosis involves low B12 levels, high MMA levels (almost universally), macrocytic anemia resembling gastritis due to B12 deficiency; hypochlorhydria with high gastrin; positive anti-parietal cell antibodies; and positive anti-intrinsic factor antibodies. The treatment is b12 replacement therapy without using the Schilling test as it's not relevant for USMLE exams.

The Schilling test is no longer done for atrophic gastritis diagnosis. Endoscopy and biopsy are the only ways to diagnose it, with visible macroscopic changes such as decreased rugal folds. Chronic inflammation damages parietal cells, leading to reduced secretion of hydrochloric acid and intrinsic factor, causing a chlorhydria or hypo-chlorhydrea and low B12 levels.