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Gastroenterology and HepatologY Complications of PUD: o Penetration is characterized by a gradual increase in the severity and f'requency of abdominal pain, with acute pancreatitis as a common presentation. . Perforation is characterized by severe, sudden abdominal pain that is often associated with shock and peritoneal signs' . Outlet obstruction is characterized by nausea, vomiting, and/or early satiety and a succussion splash. . Bleeding is characterized by hematemesis. melena, or hematochezia (see Upper GI Bleeding). Testing PUD is most otten diagnosed by upper endoscopy. Diagnostic tests flor H. pylori should be obtained. Options include: r gastric biopsies during upper endoscopy . l3C-urea breath test . stool antigen test . serologic testing (ELISA fbr IgG antibodies) DON'T BE TRIGKED . Negative testing for H. pylori completed in the acute setting should be repeated after discharge. o False-negative rapid urease tests, urea breath tests, and stool antigen results for H. pylorimay occur in patients who recently took antibiotics, bismuth containing compounds, or PPIs; these drugs should be stopped before testing (zS days for antibiotics, 2 weeks for PPIs) or histologic assessment for H. pyloriis performed. . Serum antibody testing for H. pylori will not differentiate between past and current infection; a negative test excludes infection, but a positive test cannot confirm current infection. o Duodenal ulcers carry little risk for malignancy and do not require biopsy unless they are refractory to therapy. Treatment For uncomplicated PUD, begin once daily PPI and stop any aspirin or NSAIDs. Treat H. pylori if present. SIUDY TABLE! Treating Aspirin or NSAID-lnduced Bleeding Peptic Ulcer Disease lf you see this... Do this... Aspirin for secondary prevention of CVD Restart aspirin 1-7 days after initiation of PPl, and continue PPI indefinitely NSAID cannot be stopped permanently COX-2 inhibitor plus PPI Initial H. pylori therapy should be based on assessment of the probability of high resistance rates to clarithromycin (previous treatment with a macrolide, local resistance rates >15'1,, or eradication rates with clarithromycin based triple therapy <85'7,).

SIUDY TABLE! Treating Aspirin or NSAID-lnduced Bleeding Peptic Ulcer Disease lf you see this... Do this... Aspirin for secondary prevention of CVD Restart aspirin 1-7 days after initiation of PPl, and continue PPI indefinitely NSAID cannot be stopped permanently COX-2 inhibitor plus PPI Initial H. pylori therapy should be based on assessment of the probability of high resistance rates to clarithromycin (previous treatment with a macrolide, local resistance rates >15'1,, or eradication rates with clarithromycin based triple therapy <85'7,). . If resistance to clarithromycin is unlikely, use clarithromycin based triple therapy. o If resistance to clarithromycin is probable, use bismuth quadruple therapy. When first line therapy fails, a salvage regimen (administered for at least 14 days) should avoid previously used antibiotics. Follow-up Follow up noninvasive testing trl document H. pylori eradication should be performed 4 weeks after completion of therapy by using a r3C urea breath test, fecal antigen test, or gastric biopsy. Follow up upper endoscopy for gastric ulcers is indicated if biopsies were not performed during initial upper endoscopy. 86

Gastroenterology and Hepatology DOil'T BE TRICKED . Duodenal PUD without complications does not require follow-up upper endoscopy. . Serologic testing should not be used to confirm H. pylori eradication, because results may remain positive in the absence of active infection. TESTYOURSELF A 42-year-old man was treated with a PPI, amoxicillin, and clarithromycin for an H. pylori positive duodenal ulcer. He returns 9 weeks after treatment because of recurrent symptoms. ANSWER: For management, select urea breath test. If positive, re-treat with antibiotics different from those prescribed initially for at least 14 days. Nonulcer Dyspepsia Diagnosis Nonulcer dyspepsia is defined as nonspecific upper abdominal discomfort or nausea not attributable to PUD or GERD. Diagnosis is based on the presence of one or more of the following symptoms: o bothersomepostprandial fullness . early satiety . epigastric burning Various drugs may cause dyspepsia, including NSAIDs, antibiotics, bisphosphonates, and potassium supplements. Testing Endoscopy is indicated only for: . patients aged >60 years . younger patients at high risk for malignancy (multiple and severe alarm features or immigration from Asia, Russia, or South America) Treatment If possible, discontinue all medications that cause dyspepsia. For patients aged 560 years without alarm features, implement a test-and-treat approach for H. pylori. For those who test negative for H. pylori, implement an empiric trial with a PPI for 4 to 6 weeks. DOil'T BE TRICKED o Patients with refractory symptoms despite empiric therapy should undergo upper endoscopy 87