Gastric Ulcer

• • Epigastric pain

  • Ulcer demonstrated by endoscopy or radiography

  • Acid present on gastric analysis

Epidemiology

• • 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

Symptoms and Signs

• • 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

Laboratory Findings

• • Evaluation for H pylori infection

Imaging Findings

• • Radiographic or endoscopic evidence of gastric ulceration

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

Rule Out

• • 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

• • Signs and symptoms of gastric ulcer

  • Radiographic or endocopic findings consistent with gastric ulcer

  • Biopsy to exclude malignancy

  • Testing for H pylori

When to Admit

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

• • 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

Surgery

• • Parietal cell vagotomy

  • Truncal vagotomy and antrectomy

  • Vagotomy and pyloroplasty

Indications

• • Intractibility: Excision of ulcer and acid reduction

  • Perforation, bleeding, obstruction

Medications

• • Treatment of H pylori

  • Antacids

  • H2 receptor blockers

  • Proton pump inhibitors

Treatment Monitoring

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

Complications

• • Perforation

  • Obstruction

  • Bleeding

Prognosis

• • < 5% recurrence after vagotomy and antrectomy

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

Prevention

• • Avoidance of NSAIDs

References