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Disorders of the Stomach and Duodenum Peptic Ulcer Disease For bleeding PUD related to aspirin use for secondary cardiovascular prevention, aspirin should be restarted 1 to Clinical Features, Diagnosis, and Complications 7 days after initiation of PPI and cessation of bleeding. PPI The most frequently reported symptom of peptic ulcer disease therapy can be discontinued after confirmation of H. pylori (PUD) is epigastric pain, often described as worse during eradication in patients with H. pylori-associated bleeding fasting and improved with eating or use of antacid or antise- PUD. NSAIDs should be discontinued in patients with NSAID- cretory therapy. Pain may be accompanied by early satiety, induced bleeding PUD. If there is no effective alternative to abdominal bloating, nausea, belching, or heartburn. Epigastric NSAIDs, a selective cyclooxygenase-2 inhibitor plus a once- pain may be minimal or absent in elderly patients, immuno- daily PPI should be used. Patients with idiopathic ulcers that suppressed patients, and patients receiving long-term NSAID have bled should receive once-daily PPI therapy indefinitely therapy. because of the substantial risk for rebleeding. NSAIDs and H. pylori infection are the most common Repeat upper endoscopy to verify ulcer resolution should causes of PUD, although idiopathic (NSAID-negative, H. pylori- be reserved for patients who have persistent symptoms after 8 negative) PUD is increasingly visible as a cause in the United to 12 weeks of therapy, have ulcers of unknown cause, or did States as the incidence of H. pylori infection falls. The causes not undergo gastric ulcer biopsy during initial upper of idiopathic PUD remain unclear; however, cocaine, metham- endoscopy. phetamine, bisphosphonates, selective serotonin reuptake Perforated PUD is a surgical emergency, with a mortal- inhibitors, smoking, excessive alcohol consumption, and ity rate of up to 30%; older age, comorbidity, and delayed stress have been implicated. Rare causes of PUD include gas- surgery increase risk. Prompt identification, urgent surgical trinoma (Zollinger-Ellison syndrome), systemic mastocytosis, intervention, and proper preoperative and postoperative a,-antitrypsin deficiency, COPD, chronic kidney disease, gas- management of sepsis are essential. The cause of PUD tric cancer, gastric lymphoma, Crohn disease, eosinophilic (H. pylori and/or NSAIDs) should be addressed, and postop- gastroenteritis, herpes simplex virus, and cytomegalovirus erative upper endoscopy to rule out gastric cancer should be (in immunocompromised patients). considered. PUD is most often diagnosed by upper endoscopy. Patients with gastric outlet obstruction from inflamma- Complications of PUD include bleeding, perforation, and tion or scarring at the pylorus or proximal duodenum should obstruction. Overt bleeding presents with melena, hematem- have biopsy at the time of diagnosis to exclude malignancy. esis, and/or hematochezia, whereas obscure bleeding may For mild symptoms, PPI therapy, treatment of H. pylori present with iron deficiency anemia and/or stool that is posi- infection (if identified), and/or cessation of NSAIDs may be tive for occult blood. Perforation typically presents with sud- effective. For severe or persistent symptoms, endoscopic den, severe epigastric pain that can become more generalized dilation should be pursued, with surgery reserved for persis- along with peritoneal findings. Abdominal CT is the diagnostic tent obstruction following repeated attempts at endoscopic study of choice for suspected perforating PUD (sensitivity, dilation. 98%). Symptoms associated with obstruction may include vomiting, early satiety, abdominal distention, and weight loss.

Peptic Ulcer Disease For bleeding PUD related to aspirin use for secondary cardiovascular prevention, aspirin should be restarted 1 to Clinical Features, Diagnosis, and Complications 7 days after initiation of PPI and cessation of bleeding. PPI The most frequently reported symptom of peptic ulcer disease therapy can be discontinued after confirmation of H. pylori (PUD) is epigastric pain, often described as worse during eradication in patients with H. pylori-associated bleeding fasting and improved with eating or use of antacid or antise- PUD. NSAIDs should be discontinued in patients with NSAID- cretory therapy. Pain may be accompanied by early satiety, induced bleeding PUD. If there is no effective alternative to abdominal bloating, nausea, belching, or heartburn. Epigastric NSAIDs, a selective cyclooxygenase-2 inhibitor plus a once- pain may be minimal or absent in elderly patients, immuno- daily PPI should be used. Patients with idiopathic ulcers that suppressed patients, and patients receiving long-term NSAID have bled should receive once-daily PPI therapy indefinitely therapy. because of the substantial risk for rebleeding. NSAIDs and H. pylori infection are the most common Repeat upper endoscopy to verify ulcer resolution should causes of PUD, although idiopathic (NSAID-negative, H. pylori- be reserved for patients who have persistent symptoms after 8 negative) PUD is increasingly visible as a cause in the United to 12 weeks of therapy, have ulcers of unknown cause, or did States as the incidence of H. pylori infection falls. The causes not undergo gastric ulcer biopsy during initial upper of idiopathic PUD remain unclear; however, cocaine, metham- endoscopy. phetamine, bisphosphonates, selective serotonin reuptake Perforated PUD is a surgical emergency, with a mortal- inhibitors, smoking, excessive alcohol consumption, and ity rate of up to 30%; older age, comorbidity, and delayed stress have been implicated. Rare causes of PUD include gas- surgery increase risk. Prompt identification, urgent surgical trinoma (Zollinger-Ellison syndrome), systemic mastocytosis, intervention, and proper preoperative and postoperative a,-antitrypsin deficiency, COPD, chronic kidney disease, gas- management of sepsis are essential. The cause of PUD tric cancer, gastric lymphoma, Crohn disease, eosinophilic (H. pylori and/or NSAIDs) should be addressed, and postop- gastroenteritis, herpes simplex virus, and cytomegalovirus erative upper endoscopy to rule out gastric cancer should be (in immunocompromised patients). considered. PUD is most often diagnosed by upper endoscopy. Patients with gastric outlet obstruction from inflamma- Complications of PUD include bleeding, perforation, and tion or scarring at the pylorus or proximal duodenum should obstruction. Overt bleeding presents with melena, hematem- have biopsy at the time of diagnosis to exclude malignancy. esis, and/or hematochezia, whereas obscure bleeding may For mild symptoms, PPI therapy, treatment of H. pylori present with iron deficiency anemia and/or stool that is posi- infection (if identified), and/or cessation of NSAIDs may be tive for occult blood. Perforation typically presents with sud- effective. For severe or persistent symptoms, endoscopic den, severe epigastric pain that can become more generalized dilation should be pursued, with surgery reserved for persis- along with peritoneal findings. Abdominal CT is the diagnostic tent obstruction following repeated attempts at endoscopic study of choice for suspected perforating PUD (sensitivity, dilation. 98%). Symptoms associated with obstruction may include vomiting, early satiety, abdominal distention, and weight loss. ¢ NSAIDs and Helicobacter pylori infection are the most Management common causes of peptic ulcer disease. Following confirmation of uncomplicated PUD, a once-daily PPI should be initiated and any agent causing PUD (such as an e For bleeding peptic ulcer disease related to aspirin use

¢ NSAIDs and Helicobacter pylori infection are the most Management common causes of peptic ulcer disease. Following confirmation of uncomplicated PUD, a once-daily PPI should be initiated and any agent causing PUD (such as an e For bleeding peptic ulcer disease related to aspirin use NSAID) should be discontinued. H. pylori infection should be for secondary cardiovascular prevention, aspirin should treated ifidentified and eradication confirmed after treatment. be restarted 1 to 7 days after initiation of PPI and cessation When results of tests for H. pylori completed in the acute set- of bleeding.

NSAID) should be discontinued. H. pylori infection should be for secondary cardiovascular prevention, aspirin should treated ifidentified and eradication confirmed after treatment. be restarted 1 to 7 days after initiation of PPI and cessation When results of tests for H. pylori completed in the acute set- of bleeding. ting are negative, testing should be repeated after discharge. e NSAIDs should be discontinued in patients with NSAID- Upper endoscopy should be performed within 24 hours induced bleeding peptic ulcer disease; if there is no in patients with acute upper gastrointestinal bleeding. In effective alternative to NSAIDs, a selective cyclooxygenase-2 patients with bleeding PUD, factors that increase risk for inhibitor plus a once-daily PPI should be used. recurrent bleeding and/or death include tachycardia, hypo- e Patients with idiopathic ulcers that have bled should tension, age older than 60 years, hemoglobin level less than receive once-daily PPI therapy indefinitely because of 7 g/dL (70 g/L) (8 g/dL [80 g/L] in patients with cardiovascular the substantial risk for rebleeding. disease), and comorbid illness. Interventions to address modi- e Repeat upper endoscopy to verify ulcer resolution is HVC fiable risks should be pursued before upper endoscopy. reserved for patients who have persistent symptoms Nasogastric tube placement is not required before upper after 8 to 12 weeks of therapy, have ulcers of unknown endoscopy. Use of PPIs before upper endoscopy may improve cause, or did not undergo gastric ulcer biopsy during the endoscopic appearance of ulcer and reduce the need for the initial upper endoscopy. endoscopic therapy. 12