32 HOW TO TREAT: PEPTIC ULCER DISEASE
32 HOW TO TREAT: PEPTIC ULCER DISEASE
22 AUGUST 2025 ausdoc. com. au recommended time line for evaluation is within 24 hours of presentation to hospital. 45 Like the duration and dosing of PPI therapy, the need for endoscopic therapy is guided by the Forrest classification. Patients with a Forrest 2C or Forrest 3 ulcer, a flat pigmented spot or clean base, do not need endoscopic treatment. 45 Therapy is recommended in Forrest 1A to Forrest 2A lesions. Combination treatment is recommended for Forrest 1A and 1B lesions, typically consisting of dilute adrenaline injections plus a second modality that may include thermal therapy, mechanical agents such as clips or sclerosant injections. In those with duodenal ulcers, repeat gastroscopy is not routinely recommended following evaluation of a peptic ulcer and administration of appropriate treatment; however, consider this in those with persistent symptoms despite an appropriate course of therapy. 46
In contrast, consider routine surveillance endoscopy 8-12 weeks post-index endoscopy in those with gastric ulcers. This is because ulcers may initially appear endoscopically and histologically benign but may eventually prove malignant. 46 Individualise this decision in consultation with the treating gastroenterologist. Routine biopsy is not typical for duodenal ulcers but is recommended for gastric ulcers because of the risk of malignancy. 46
Endoscopic evaluation is not recommended in cases where clinical features are suggestive of acute perforation; surgical closure is the recommend approach. 46
Radiological and surgical therapy
While endoscopic therapy is the primary modality for the management of bleeding peptic ulcers, radiological and surgical management may be required in certain circumstances. This is typically in the setting of bleeding refractory to endoscopic management. A repeat endoscopic assessment and attempt at haemostasis is typically recommended in the first instance of a recurrent bleed. 45 If endoscopic treatment is not successful, input from a multidisciplinary team, consisting of gastroenterologists, interventional radiologists and surgeons is used to determine the optimal treatment approach. Factors considered include patient comorbidities and local centre expertise. An interventional radiological approach is the first modality generally utilised following failed endoscopic management, with transcatheter angiographic embolisation( TAE) attempted. 45 This is utilised first because it results in marked reduction in complications and hospital stay, with no difference in mortality, compared with surgical intervention. When TAE is not available or is not successful, patients proceed to surgical intervention.
Surgery is often the first-line management in cases of perforation secondary to peptic ulcers. The choice
How to Treat Quiz.
1. Which THREE statements about peptic ulcer disease are correct? a Multiple aetiological factors contribute to the disease. b NSAIDs and aspirin increase the risk of complications from the disease. c All patients with H. pylori develop the disease. d About 20 % of cases of the disease are H. pylori and / or NSAID negative.
2. Which TWO are risk factors for peptic ulcer disease? a Spicy food. b Smoking. c Alcohol use. d Diet high in fibre.
3. Which THREE statements regarding the epidemiology of peptic ulcer disease are correct? a It is more common in women than in men. b Its incidence increases with age for both duodenal and gastric ulcers. c Its prevalence has declined in developed countries. d Complications of the disease arise in 10-20 % of patients.
4. Which ONE is not a red flag in peptic ulcer disease? a Unexplained weight loss. of surgery depends on the individual patient’ s characteristics, their comorbidities, the location of ulcer, haemodynamic stability, and complications such as perforation or bleeding. 47
PROGNOSIS
THE outcomes for patients with peptic ulcer disease are generally favourable. Around 60 % are estimated to heal spontaneously, increasing to greater than 90 % with appropriate eradication of H. pylori, reflecting the integral role of addressing H. pylori in modulating outcomes. 34, 48-51 In individuals with complications from peptic ulcer disease, the outcomes are unsurprisingly poorer, with average 30-day mortality estimated to be 8.6 % for bleeding and 23.5 % after perforation. 52 Older
The outcomes are generally favourable with around 60 % of peptic ulcers estimated to heal spontaneously.
age, comorbidities, shock, and delayed treatment were associated with increasing mortality. 52 Fortunately, the rates of complicated disease remain low with annual incidence estimates of 19.4-57 per 100,000 for peptic ulcer haemorrhage and 3.8-14 per 100,000 for perforation. 52 Established risk factors for complications and their recurrence, aside from NSAID use and H. pylori infection include a peptic ulcer size of 1cm or greater. 52
CASE STUDIES
Case study one
DAVID, a 31-year-old lawyer, presents to his GP complaining of
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b Dyspepsia. c Severe and persistent abdominal pain. d Gastrointestinal bleeding.
5. Which THREE statements regarding the presentation of peptic ulcer disease are correct? a Patients with duodenal ulcers may report worsening abdominal pain while the stomach is empty. b Heartburn and regurgitation are symptoms typically associated with GORD rather than peptic ulcer disease. c Patients with peptic ulcers may report the food-provoked symptoms of nausea, vomiting, postprandial fullness and bloating. d Its symptoms are usually worse in older patients.
6. Which TWO factors related to H. pylori create an environment conducive to the development of gastric carcinoma? a Butyrate concentration. b Oxidative stress. c DNA damage to the cells. d Presence of lipase.
7. Which ONE is the gold standard investigation for evaluating peptic ulcer disease? a Urea breath test plus stool antigen testing. b Abdominal CT. c Gastroscopy. d Serology testing.
8. Which THREE are appropriate in the management of peptic ulcer disease? a H. pylori eradication with triple therapy when present. b Confirmation of H. pylori eradication with a urea breath test. c Duration and dosing of PPI is dependent on the underlying aetiology of the ulcer, its location and the presence of complications. d Oral PPI therapy for all patients with a suspected bleed secondary to a peptic ulcer.
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PEPTIC ULCER DISEASE
burning epigastric pain on awaking each morning. This has been ongoing for the past year. He is otherwise well; he does not report weight loss, haematemesis, melaena, dysphagia or night sweats. David is not on any regular medications, has no other past medical history and does not have any allergies. He denies any family history of gastrointestinal malignancy and is a lifelong nonsmoker. Bloods tests reveal an FBC within normal limits and normal iron studies.
The GP orders a urea breath test, which is positive for H. pylori. David is prescribed eradication therapy for 14 days. He subsequently undergoes a confirmatory urea breath test two weeks post-completion of therapy, which yields a negative result. He is symptom free at the time of further review six weeks later.
In this case the epigastric pain may be from peptic ulcer disease or helicobacter-associated gastritis. However, given the absence of red flags and the stable clinical characteristics of the patient, a diagnostic gastroscopy is not required before initiating empirical treatment.
Case study two
Mary, a 47-year-old teacher, presents to her GP complaining of worsening heartburn. This has been present for the past four weeks and is associated with burning epigastric abdominal pain.
She denies any weight loss, haematemesis, dysphagia or night sweats, though does report some possible black stools about two
9. Which THREE statements regarding the management of peptic ulcer disease are correct? a Routine biopsy is recommended for duodenal and gastric ulcers because of the risk of malignancy. b Peptic ulcers complicated by bleeding and perforation require high-dose PPI therapy for eight weeks. c Surgical closure is the recommended approach when clinical features are suggestive of acute perforation. d Radiological and surgical management may be required in bleeding refractory to endoscopic management.
10. Which TWO statements regarding the prognosis of peptic ulcer disease are correct? a Appropriate eradication of H. pylori aids in ulcer healing. b Established risk factors for complications and their recurrence, aside from NSAID use and H. pylori infection, include a peptic ulcer size of 2cm or greater. c Older age, comorbidities, shock and delayed treatment are associated with increased mortality. d The outcomes for patients with the disease are generally poor. weeks prior. She denies any other past medical history, has no family history of gastrointestinal malignancy and is a lifelong non-smoker. Mary takes perindopril for hypertension and rosuvastatin for hypercholesterolaemia. She reports she has been taking ibuprofen for the past four weeks in the setting of a recent ankle sprain. Blood tests reveal a microcytic anaemia with a haemoglobin of 95g / L( normal range above 120g / L) and a normal urea. A urea breath test is negative for H. pylori.
The GP refers Mary to the ED for assessment. She undergoes a gastroscopy that demonstrates a Forrest 3 duodenal ulcer. An iron infusion is administered before discharge and Mary is advised to avoid taking NSAIDs and is prescribed PPI twice daily therapy for eight weeks. On review 10 weeks later she is no longer taking her PPI and is symptom free.
Case study three
John is a 70-year-old retiree who presents to his GP with a threemonth history of epigastric pain and persistent nausea and vomiting. He denies any haematemesis, melaena, dysphagia or night sweats, though reports 4kg weight loss in the last month in the setting of reduced appetite secondary to pain. John is an ex-smoker with a 20 pack-year history. He denies any other medical history, and there is no family history of gastrointestinal malignancy. John does not take any regular medications but does take the occasional paracetamol and ibuprofen for lower back pain.
He is able to pass stool and his abdomen is soft and non-tender with no evidence of organomegaly or masses.
Blood tests reveal an FBC within normal limits and normal kidney function and iron studies. A urea breath test is negative. The GP refers John to the gastroenterology outpatient department for consideration of endoscopic assessment. He undergoes a gastroscopy which shows a 20mm Forrest 2C ulcer at the pylorus causing some gastric outlet obstruction. John is prescribed PPI therapy twice daily for eight weeks and advised to avoid NSAIDs. A repeat gastroscopy performed 12 weeks later demonstrates near resolution of the ulcer; biopsies taken from the ulcer edge show no evidence of malignancy or dysplasia.
CONCLUSION
PEPTIC ulcer disease is a highly prevalent condition in the population driven by H. pylori infection along with rates of NSAID use. While endoscopic assessment may be required, particularly in those with red flag symptoms, a significant number of patients can have a considerable amount of their management started in the primary care setting; through early recognition of symptoms, utilisation of testing to detect H. pylori and prescription of appropriate eradication therapy. By doing this, both the rate of progression to complicated disease and the associated increased risks of morbidity and mortality can be minimised.
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