Informasjon, veiviser

Peptic ulcer disease

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Diagnosis

Diagnostic criteria

  • Upper GI endoscopy is the diagnostic gold standard
  • Radiology has a clearly lower sensitivity, ulcers are overlooked and the method does not allow for biopsy
  • Medical history identifies only 20-40% of the patients with peptic ulcer

Differentials

  • Functional dyspepsia
  • Gastrooesophageal reflux disease
  • Gastric cancer
  • Gallstone disease

History

Symptomatology

  • Symptoms in peptic ulcer disease occur periodically, they vary strongly and are to a small extent typically19-20
  • The intensity of the symptoms fluctuate from day to day and during the same day21
  • Symptoms are usually relieved by eating and antacids, although nearly half the patients deny such meal-related association
  • About 2/3 of patients with duodenal ulcer and 1/3 of patients with gastric ulcer experience night pains that may awake them
  • Nausea, vomiting, early satiety and anorexia are more prominent among patients with gastric ulcer than with duodenal ulcer
  • Anorexia and weight loss increases the suspicion of malignancy

Predictive value of medical history

  • The natural course and the clinical presentation of peptic ulcer disease varies between individual populations22-24
  • Low predictive value
    • The medical history has a limited diagnostic value - positive predictive value is only about 25% in general practice
    • Among previously non-endoscoped patients only 1 in 4 in whom the physician predicts an ulcer, will prove to have an ulcer at endoscopy
  • Following factors are the best anamnestic indicators of peptic ulcer19:
    • Age above 40 years
    • Relief from eating, although half the patients reject such an association
    • Relief from antacids
    • Night pains
    • Smoking
    • Even if all these factors are present, the probability of having a peptic ulcer is not higher than 50%
  • NSAIDs or salicylates
    • Significantly increase the risk of peptic ulcer, and this risk is further increased with length of treatment and dosage
    • About 30-50% av these ulcers are asymptomatic (camuflated by the analgesic effect of the drugs)

Complicated peptic ulcer

  • Unreliable symptoms
    • Although the majority of these patients have dyspepsia in advance, up to 20% of patients with gastric bleeding have been symptomfree until the bleeding started
    • In patients with NSAID-induced complications, nearly 60% have no symptoms in advance, maily due to the analgesic effect
  • Bleeding
    • Anemia, hematemesis, melena and detection of fecal occult blood may indicate bleeding
  • Penetration and perforation
    • Persistent upper abdominal pain which radiculate to the back may indicate penetration
    • A dramtic increase in pain indicates a perforated peptic ulcer
  • Retention
    • Vomiting indicates obstruction
  • Malignancy
    • Anorexia and weight loss may indicate cancer

Physicals

  • No specific findings influence the probability of a peptic ulcer
  • Usually the clinical examination is normal
    • Still, it is important to perform a clinical examination in order to exclude other explanations of the patients symptoms
  • In acute illness caused by a bleeding or perforated ulcer the clinical examination is decisive to judge the severity of the condition

Lab tests in general practice

Biochemical tests

  • Except for detection of fecal blood, no tests have any positive predictive value in peptic ulcer disease
  • Detection of fecal blood may indicate a small bleeding from a peptic ulcer and demands further exploring
  • In the diagnostic workup of dyspepsia other tests may also be useful

Detection of fecal Hp-antigen

  • A monoclonal antibody kit is available, provides stabile responses and has a sensitivity of 95% and specificity of 97% according to one study25 - and is less expensive than the urea breath test, but costs more than serologic tests
  • Disadvanteges
    • The patient must stop the intake of proton pump inhibitor at least two weeks prior to the test or H2-antagonist at least one day before the test26
    • Antibiotics should not have been taken the last four weeks
  • Method
    • The test applies laboratory methods similar to the serologic tests, and the test may be used in general practice27
  • Usefulness
    • The test can be applied both in the diagnostic workup and to confirm the eradication of the infection following treatment26,28

Serology?

  • Should be substituted by fecal antigen test
  • Can be useful in the workup of dyspepsia
  • Rapid tests versus ELISA-tests
    • Rapid tests have lower sensitivity (85% vs 95%) and lower specificity (70-90% vs 90-95%)29-31
    • Thus, rapid tests have a higher probability of both false positive and false negative results and therefor should be omitted
  • Test of treatment effect?
    • Serology is unreliable in the control of the effect of anti-Hp-therapy, the antibody titer is declining slowly over months and years

Hp-status and clinical implications

  • Patients under 50 years
    • Should be tested
    • A positive test implies that endoscopy should be done, or test-and-treat32-34
    • A negative test almost excludes organig disease, and there should be no need to do endoscopy
  • Patients over 50 years
    • Need not be tested, they should be referred to have an upper GI endoscopy

Investigations

Upper GI endoscopy

  • Diagnosis is verified by endoscopy, which also allows for biopsy of gastric ulcers and invasive tests of H pylori32
    • PCR is the preferred test
    • Alternatives are rapid urease test, culture with test of resistence, and histology
  • Biopsy
    • Is done to exclude malignancy
    • Five percent of gastric ulcers are malignant
    • 8-10 samples are taken from the edge of the ulcer, an alternative is brush cytology
    • Duodenal ulcer are almost never malignant, and they need not be biopsied
  • Erythromycin prior to endoscopy for acute upper gastrointestinal haemorrhage?
    • Erythromycin is a potent stimulator of gastrointestinal motility. Studies have shown that intravenous erythromycin fastens the clearance of blood from the stomach before oesophago-gastroduodenoscopy (EGD) for acute upper gastrointestinal haemorrhage (UGIH) (Ia)35
    • Because of the implications for cost saving and increase in QALY, it is recommended to give erythromycin prior to EGD for UGIH

Lab tests in hospitalized patients

  • Hb, bloodtyping in bleeding
  • Measurements of serum-gastrin if Zollinger-Ellison's syndrom is suspected (multiple ulcers)

Radiology?

  • Double-contrast radiography performed by an experienced radiologist might approach the diagnostic accuracy of upper GI endoscopy (70% versus 95%). However, it has been replaced largely by diagnostic endoscopy, when available
  • Radiology could be indicated to rule out malignancy, in particular linitis plastica
    • In such situations CT and MRI should be considered

Hp-tests in bleeding peptic ulcer

  • The following is based on a systematic review (Ia)36
  • Biopsy-based methods like rapid urease test, histology and culture have low sensitivity, bur high specificity
  • Radioactive labelled urea breath test has high diagnostic accuracy
  • Fecal antigen test is less accurate
  • Serology can not be recommended as the initial diagnostic test under such circumstances

Referral

  • It is unnecessary to refer patients with known duodenal ulcer disease, except when there is complications or strikingly changes in the symptomatology
  • Patients with earlier gastric ulcer should be considered for a new upper GI endoscopy when symptoms relapse - there is alway a risk for underlying malignancy
  • Relapse in a patient who has been adequately treated with anti-Hp-therapy, but who is still Hp-positive, may need a bacterial resistance determination
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