Peptic ulcers

• Can be gastric or duodenal
• Duodenal Ulcers: Epigastric pain relieved by eating
  – Pain 2-3 hours after meals
  – Night pain that awakens patient (more common)
• Gastric Ulcers: Epigastric pain worsened by eating
  – Pain shortly after meals
• Risks – regular aspirin/NSAIDs
• Treat with standard dose PPR for 4-8 weeks
• If need to remain on NSAID consider long term PPI

Common Risk Factors for Both Peptic and Duodenal Ulcers

• Helicobacter pylori Infection: Strongly associated with both peptic and duodenal ulcers.
• Non-Steroidal Anti-Inflammatory Drugs (NSAIDs): Use of NSAIDs such as ibuprofen, aspirin, and naproxen can inhibit prostaglandin synthesis, reducing the protective mucus in the stomach lining.
• Smoking: Increases acid production and decreases bicarbonate production, impairing mucosal defense.
• Alcohol Use: Can irritate and erode the stomach lining, increasing acid production.
• Stress: Acute physiological stress (e.g., severe illness, surgery) can increase the risk of ulcers.
• Dietary Factors: Spicy foods, caffeine, and high-fat meals can exacerbate symptoms but are not direct causes of ulcers.
• Family History: A family history of ulcers can increase the risk.
• Causes chronic inflammation and damage to the stomach and duodenal lining.
• Hypersecretory States: Conditions like Zollinger-Ellison syndrome, which involves tumors that increase gastrin production, leading to excessive acid production.

Indications for gastroscopy

1. Alarm symptoms:
   1. Anaemia
   2. Dysphagia
   3. odynophagia
   4. Haematemesis &/or malaena
   5. Vomiting
   6. Weight loss
   7. family history of gastrointestinal cancer
   8. previous esophagogastric malignancy
2. New symptoms in an older person >55yrs
3. Changing symptoms
4. Severe or frequent symptoms
5. Inadequate response to treatment

Other: Diagnostic clarification of symptoms

Management

1^st line: Lifestyle changes

1. Avoid trigger foods eg. High fat meals, alcohol, coffee, chocolate, citrus
2. Weight loss if overweight
3. Eat smaller meals
4. Drink fluids mostly between meals, rather than with meals
5. Avoid lying down after eating

Other: avoid E&D 2-3hrs before bedtime or vigorous exercise, elevate head of bed if nocturnal symptoms, smoking cessation

2^nd line: Antacids PRN

1. Antacid + alginate 10-20ml PO eg. Gaviscon
2. Magnesium + aluminium hydroxide 10-20mL PO eg. Mylanta

3^rd line:

1. H2 receptor antagonists eg. Ranitidine 150mg PO 1-2x/day PRN
2. PPI (20-30mins before meals) PRN eg. Pantoprazole 40mg daily

Mild intermittent symptoms	Frequent or severe symptoms = ≥ 2x episodes/week or symptoms severe enough to impair QOL
Lifestyle measures Antacids PRN H2 receptor antagonists/ PPIs PRN	Lifestyle measures Daily PPI, for 4-8 weeks initially. Then step down to maintenance therapy (half dose or dose on alternative days, then step down to PRN use) Laparoscopic fundoplication

Potential AE from use of PPIs (short and long term use)

1. Interstitial nephritis
2. Hypomagnaesmia
3. ↑ risk of pneumonia
4. C.difficile + other GI infections
5. Impaired nutrient absorption

Other: ↑ risk of fracture

Special populations

Pregnancy

• Common
• Mx: 
  • Lifestyle modifications
  • H2 receptor antagonists – safe
  • PPI – omeprazole (cat B3: limited number of preg women have taken it w/out ↑ in harm to fetus; studies in animals however have shown ↑ in fetal harm)

Children

• May be associated with vomiting & regurgitation
• Common in infants, improves by 12 months age
• Presentation:
  • FTT
  • Oeseophagitis
  • Stricture
  • Refusing to feed
  • Recurrent pneumonia
  • anaemia
  • dental erosions
  • apnoea
• Mx:
  • Smaller but more frequent feeding
  • Thickened feeds eg. With rice cereal, corn starch
  • Elevating head of cot
  • Trial of PPI: eg. esomeprazole 0.7mg/kg (max 20mg) orally daily (granules can be dispersed in water)
• When to refer:
  • FTT
  • apnoea or aspiration
  • dysphagia
  • haematemesis
  • melaena
• DDx:
  • Cow’s milk protein allergy
  • Soy protein allergy

Medications that exacerbate reflux symptoms

1. Aspirin
2. NSAIDs
3. Benzodiazepines
4. Bisphosphonates
5. Calcium channel blockers

Other: meds with anticholinergic effects (eg. TCA), nitrates