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accuracy of these tests is usually
affected by concurrent PPI use and may result in false negatives.
H. pylori serology is the only method that is not affected by the use of acid-suppressing medications but is a less accurate method of testing for H. pylori.
CT
Abdominal CT imaging may be sug-
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Jeremias / CC BY-SA 3.0 / bit. ly / 3LN9vjH |
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gestive of the diagnosis if there is | ||||
evidence of increased gastric wall | ||||
thickening, focal mucosal enhancement | ||||
or perigastric / periduodenal | ||||
inflammation. 32 | ||||
Where there is suspicion of complications | ||||
, an abdominal CT scan is a valuable | ||||
non-invasive modality. It may | ||||
identify gastric perforation, abscess | ||||
formation and active bleeding( if performed | ||||
with angiography). | ||||
CT allows for assessment of the | ||||
extent of ulcer disease and the impact | ||||
on adjacent structures; it is especially | ||||
helpful when endoscopy cannot provide | ||||
a complete view of the affected | ||||
region or assess structures outside | ||||
the gastrointestinal tract. | ||||
Note that abdominal CT is not | ||||
sensitive in detecting uncomplicated |
disease and may not detect superficial ulcers. 33 |
Figure 6. Bleeding gastric ulcer. |
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Gastroscopy
An upper endoscopy is the gold standard investigation for diagnosis. This minimally invasive procedure involves endoscopic assessment of the oesophagus, stomach and duodenum. The procedure allows for direct visualisation and identification of gastric / duodenal ulcers and an assessment of ulcer size, location and presence of complications. An upper endoscopy also allows for therapeutic management— includ-
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A |
Epomedicine 2013; 15 Nov./ bit. ly / 3REsUqV |
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ing treatment of ulcers and collection |
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of biopsies, which helps to identify |
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potential aetiologies for peptic ulcer |
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disease and is especially useful in the |
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determination of antimicrobial sensitivities |
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for H. pylori. |
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MANAGEMENT
TREATMENT typically involves management
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of the underlying ulcer aetiology |
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and antisecretory therapy. Complications, such as bleeding and |
Figure 7. |
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perforation, require multidisciplinary management in an inpatient setting, with a potential combination of endoscopic, interventional radiology and surgical management.
Underlying aetiology
As noted earlier, H. pylori and the
use of NSAIDs are two key aetiolo-
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A. Technique of examining for pallor in lower palpebral conjunctiva.
B. Normal conjunctiva( note the demarcation shown by the arrow).
C. Pale conjunctiva( loss of demarcation).
B
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C |
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gies in the formation of peptic ulcer |
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disease; addressing these are key |
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to successful management. Advise |
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patients to avoid the use of NSAIDs |
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and aspirin, if possible, though the |
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practicality of this grows more challenging |
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in the setting of an increasingly |
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comorbid population. |
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H. pylori eradication( see figure 8) is |
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recommended in all patients presenting |
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with peptic ulcers where H. Pylori |
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is present, and is demonstrated to |
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increase 12-month ulcer remission rates |
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for both gastric and duodenal ulcers. 34 First-line eradication therapy in Australia |
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consists of oral triple therapy |
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with the PPI esomeprazole 20mg twice |
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daily, plus amoxycillin 1g twice daily, |
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and clarithromycin 500mg orally twice |
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daily for 7-14 days, with data suggest- |
Prescribe oral metronidazole 400mg |
with these patients typically requir- |
Confirmation of eradication is rec- |
confirm eradication at least 4-8 weeks |
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ing a 14-day duration is associated with increased success rates. 35 This regimen is estimated to result in successful |
twice daily in patients who are allergic to penicillin. 36 Secondary H. pylori resistance to clarithromycin is com- |
ing second-line salvage therapy with quinolone, bismuth or rifabutin-based regimens. Consider referral for special- |
ommended because of the potential for treatment failure. The carbon-13 or carbon-14 urea breath test is the pre- |
post-completion of therapy. The use of antibiotics and PPIs can lead to false negatives, and the latter should be |
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eradication in 85-90 % of cases. 35 |
mon post-failure of first-line therapy, |
ist care in these patients. |
ferred modality. Perform testing to |
discontinued for at least two weeks |
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