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Referral and warning signs
When to refer
Referral for Endoscopy urgently if ALARM FEATURES present or PUD complication suspected (bleeding, perforation, obstruction). Refer if symptoms persist despite adequate PPI therapy and H. pylori eradication. Refer gastric ulcers for follow-up endoscopy to confirm healing/exclude malignancy. Refer complicated cases (bleeding requiring intervention, perforation, obstruction) to surgery/gastroenterology.
Red flags
- Alarm features for dyspepsia (Weight loss, dysphagia, bleeding, anaemia, vomiting, mass)
- Signs of acute GI bleed (haematemesis, melaena, shock)
- Signs of perforation (sudden severe abdominal pain, rigid abdomen, peritonitis)
- Symptoms of gastric outlet obstruction (persistent vomiting, early satiety, weight loss)
Signs and symptoms
- Epigastric pain: Often burning, gnawing, or aching.
- - Duodenal Ulcer (DU): Pain typically occurs 2-5 hours after meals, when stomach is empty, and often at night (11pm-2am). Relieved by food or antacids.
- - Gastric Ulcer (GU): Pain may occur shortly after eating (food can aggravate it), or be less predictable. Nausea/vomiting more common than DU.
- Bloating, belching, early satiety, fatty food intolerance (non-specific dyspeptic symptoms).
- Anorexia, weight loss (more common with GU or if complication/malignancy).
- Symptoms may be episodic.
- Presentation with complications: Bleeding (melaena, haematemesis), Perforation (sudden severe abdominal pain, peritonitis), Obstruction (vomiting, early satiety, weight loss - gastric outlet obstruction).
Risk factors
- Helicobacter pylori infection (major cause)
- NSAID use (including Aspirin)
- Smoking
- High physiological stress (e.g., severe illness, burns - stress ulcers)
- Zollinger-Ellison syndrome (rare - gastrin-secreting tumour)
- Possibly alcohol, certain dietary factors (less clear evidence)
Diagnosis
Clinical assessment
Suspect based on characteristic epigastric pain pattern (esp. relation to meals, night pain). History of H. pylori or NSAID use crucial. Differentiate from GERD, gastritis, functional dyspepsia, biliary colic, pancreatitis, gastric cancer.
Investigations
- Upper GI Endoscopy (OGD): Gold standard. Allows direct visualization of ulcer, location, size, features (e.g., stigmata of recent haemorrhage). Enables biopsies to test for H. pylori (RUT, histology) and to rule out malignancy (essential for all gastric ulcers).
- Helicobacter pylori testing (non-invasive): Urea Breath Test (UBT) or Stool Antigen Test preferred for initial diagnosis (if endoscopy not immediately indicated) and to confirm eradication post-treatment.
- Barium Meal: Less sensitive/specific than endoscopy, cannot biopsy. Used if endoscopy unavailable/contraindicated.
- Blood tests: CBC (check for anaemia from chronic bleeding).
Diagnostic criteria
Endoscopic visualization of an ulcer crater in the stomach or duodenum. OR characteristic findings on Barium Meal (less preferred). Evidence of H. pylori infection supports diagnosis in relevant cases.
Management
Non-pharmacological management
- Lifestyle modification: Smoking cessation, avoid alcohol, avoid NSAIDs.
- Dietary changes have limited role, but avoid foods that trigger symptoms.
Pharmacological treatment
- Acid Suppression (Promotes healing):
- - Proton Pump Inhibitors (PPIs): Omeprazole 20-40mg OD (or equivalent PPI - Lansoprazole, Pantoprazole) for 4-8 weeks (DU usually 4 weeks, GU usually 8 weeks).
- - H2 Receptor Antagonists (H2RAs): Less effective than PPIs for healing.
- Helicobacter pylori Eradication (If H. pylori positive - CRITICAL to prevent recurrence):
- - Triple Therapy (First-line - UCG 2023): Omeprazole 20mg BID + Amoxicillin 1g BID + Metronidazole 400mg BID for 14 days. (Note: Clarithromycin-based triple therapy common elsewhere but resistance high).
- - Quadruple Therapy (Alternative/Second-line): PPI BID + Bismuth subsalicylate/subcitrate QID + Metronidazole QID + Tetracycline QID for 10-14 days.
- - Confirm eradication with UBT or Stool Antigen test ≥4 weeks after therapy completion (and off PPI for 1-2 weeks).
- Management of NSAID-induced Ulcers:
- - Stop NSAID if possible.
- - Treat with PPI for 4-8 weeks.
- - If NSAID must continue, use lowest effective dose, consider switching to COX-2 selective inhibitor (e.g., Celecoxib), AND co-prescribe PPI for gastroprotection.
- - Test for and treat H. pylori if present (increases NSAID ulcer risk).
- Management of Complications:
- - Bleeding: See UGIB section (GI003) - resuscitation, IV PPI, endoscopic therapy.
- - Perforation: Urgent surgical repair (laparotomy).
- - Obstruction: NG decompression, IV fluids, PPI, endoscopic dilation or surgery.
Monitoring
- Monitor symptom resolution.
- Confirm H. pylori eradication.
- Repeat endoscopy often recommended for GASTRIC ulcers after treatment to ensure healing and confirm benign nature (rule out underlying malignancy). Less often needed for uncomplicated DU.
Complications
- Upper Gastrointestinal Bleeding
- Perforation -> Peritonitis
- Penetration (ulcer erodes into adjacent organ e.g., pancreas)
- Gastric Outlet Obstruction (due to scarring/oedema near pylorus)
Prevention
- Eradicate H. pylori infection.
- Avoid unnecessary NSAID use.
- Use gastroprotection (PPI) with NSAIDs in high-risk individuals.
- Smoking cessation.
Patient education
- Explain PUD, likely cause (H. pylori, NSAIDs).
- Importance of completing H. pylori eradication therapy and confirming cure.
- Proper use of PPIs.
- Need to avoid NSAIDs and smoking.
- Signs of complications (bleeding, perforation) requiring urgent attention.
- Need for follow-up endoscopy for gastric ulcers.
Uganda-specific notes
H. pylori prevalence extremely high. NSAID misuse common. Diagnosis often clinical/empirical due to limited endoscopy. UCG recommends Amoxicillin+Metronidazole+PPI triple therapy. Ensure eradication testing is done where possible.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 6, Section 6.3.5