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  • • Epigastric pain

    • Ulcer demonstrated by endoscopy or radiography

    • Acid present on gastric analysis

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Epidemiology

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  • • Peak incidence at 40-60 years old

    • 85-90% of patients infected with Helicobacter pylori

    Type I ulcers (50%)

    • -Located within 2 cm of the incisura angularis

      -Gastric acid output is normal or low

    Type II ulcers (20%)

    • -Both ulceration of gastric body and duodenum

      -Increased acid secretion

    Type III ulcers (20%)

    • -Prepyloric location

      -Increased acid secretion

    Type IV ulcers (5-10%)

    • -Located high on lesser curvature at or near gastroesophageal junction

      -Gastric acid output is normal or low

    Type V ulcers (< 5%)

    • -Results from NSAID use

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Symptoms and Signs

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  • • Principal symptom is epigastric pain relieved by food or antacids

    • Vomiting, anorexia, and aggravation of pain by eating are also common

    • Epigastric tenderness may be present

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Laboratory Findings

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  • • Evaluation for H pylori infection

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Imaging Findings

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  • • Radiographic or endoscopic evidence of gastric ulceration

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  • • Signs and symptoms of gastric ulcer should prompt contrast radiography or upper endoscopy for diagnosis

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Rule Out

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  • • Ulcerated malignancy

    • -Obtain multiple biopsies from edge of the lesion

      -Rolled-up ulcer margins

      -More common with larger ulcers (> 2 cm)

    • Zollinger-Ellison syndrome if disease is severe and refractory or if associated with more distal ulceration

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  • • Signs and symptoms of gastric ulcer

    • Radiographic or endocopic findings consistent with gastric ulcer

    • Biopsy to exclude malignancy

    • Testing for H pylori

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When to Admit

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  • • Complications of gastric ulcer (bleeding, perforation, high-grade obstruction, severe pain)

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  • • Types I, IV, and V gastric ulcers represent defects in mucosal protection

    • Types II and III gastric ulcers are associated with acid hypersecretion and behave similar to duodenal ulcers

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Surgery

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  • • Parietal cell vagotomy

    • Truncal vagotomy and antrectomy

    • Vagotomy and pyloroplasty

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Indications

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  • • Intractibility: Excision of ulcer and acid reduction

    • Perforation, bleeding, obstruction

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Medications

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  • • Treatment of H pylori

    • Antacids

    • H2 receptor blockers

    • Proton pump inhibitors

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Treatment Monitoring

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  • • Repeat endoscopy after 4-16 weeks to document healing

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Complications

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  • • Perforation

    • Obstruction

    • Bleeding

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Prognosis

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  • • < 5% recurrence after vagotomy and antrectomy

    • 10-12% recurrence after parietal cell or truncal vagotomy and pyloroplasty

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Prevention

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  • • Avoidance of NSAIDs

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References

Calam J, Baron JH. ABC of the upper gastrointestinal tract: pathophysiology of duodenal and gastric ulcer and gastric cancer. BMJ. 2001;323:980.  [PubMed: 11679389]
Schubert ML. Peura DA. Control of gastric acid secretion in health and disease. Gastroenterology...

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