349.1 🎓 醫孞生版

349.1.0.1 📌 䞀頁重點

349.1.0.1.1 Peptic Ulcer Disease (PUD)
349.1.0.1.1.1 Definition
  • Mucosal break > 5 mm penetrating muscularis mucosa
  • Distinguish from erosions (superficial)
  • Duodenal ulcer (DU) more common than gastric ulcer (GU)
349.1.0.1.1.2 Etiology
  • H. pylori (70-95% DU, 60-80% GU; globally most common)
  • NSAIDs (most common in developed; 25% NSAID users develop ulcer)
  • Acid-peptic disease (some idiopathic)
  • Zollinger-Ellison syndrome (gastrinoma)
  • Stress (ICU patients)
  • Drug-induced (corticosteroids, bisphosphonates, KCl, iron)
  • Crohn’s disease
  • Vasculitis
  • Malignancy
  • Idiopathic
349.1.0.1.1.3 Clinical Features

Duodenal Ulcer: - Epigastric pain - Pain relieved by food (then recurs 2-3 hr after) - Night pain common (2-3 AM) - Patient often gains weight (eats to relieve pain)

Gastric Ulcer: - Epigastric pain - Pain worsened by food - Pain unrelieved by antacids initially - Weight loss

General: - Variable presentation - Some asymptomatic (especially NSAID) - Bloating, belching, nausea

349.1.0.1.1.4 Complications

Bleeding (Most Common): - 15-20% lifetime risk - Melena, hematemesis - See Ch346

Perforation: - Sudden, severe pain - Free air on imaging - Surgical emergency

Penetration: - Into pancreas, biliary

Gastric Outlet Obstruction: - Vomiting, weight loss - From edema or scar

Malignancy: - Especially GU - All GU need biopsy

349.1.0.1.1.5 Diagnosis

EGD: - Gold standard - Direct visualization - All GU need biopsy (rule out cancer) - DU rarely malignant

H. pylori Testing: - Urea breath test (UBT): sensitive + specific; preferred non-invasive; off PPI 2 wk - Stool antigen: similar; cheaper; convenient - Biopsy + CLO test (urease) during EGD - Histology with biopsy: gold standard with EGD - Serology (IgG): less specific; doesn’t distinguish current; useful epidemiology

349.1.0.1.1.6 Treatment

H. pylori Eradication:

Quadruple Therapy (Preferred): - Bismuth subsalicylate 525 mg QID - PPI BID - Tetracycline 500 mg QID - Metronidazole 500 mg TID - 14 days - Effective even with clarithromycin resistance

Triple Therapy (Clarithromycin-Based): - PPI BID + clarithromycin 500 mg BID + amoxicillin 1 g BID (or metronidazole 500 BID if penicillin-allergic) - 14 days - Only if local clarithromycin resistance < 15% - Worsening resistance globally — quadruple preferred

Vonoprazan-Based Therapy (FDA 2022): - Vonoprazan 20 mg BID + amoxicillin 1 g TID (“dual”) - Vonoprazan 20 mg BID + amoxicillin 1 g TID + clarithromycin 500 mg BID (“triple”) - 14 days - Higher eradication rates - FDA approved 2022

Levofloxacin-Based (rescue): - PPI + amoxicillin + levofloxacin - If failure of standard regimens

Verification: - 4+ weeks after completion - Off PPI 2 weeks - Urea breath test or stool antigen

PPI Therapy: - Healing: 4-8 weeks - Indefinite if NSAID continues or recurrent - Lifelong if Barrett’s, ZES, severe esophagitis

NSAID-Induced: - Discontinue NSAID if possible - Switch to COX-2 selective (less risk) - Add PPI for prophylaxis

Treatment of Bleeding: - See Ch346 - EGD with endoscopic therapy (clips, thermal, injection) - PPI infusion - Surgery if uncontrolled

Surgical Treatment (Rare Now): - Vagotomy + drainage - Antrectomy + vagotomy - For refractory or complicated

349.1.0.1.2 Functional Dyspepsia
349.1.0.1.2.1 Rome IV Criteria
  • Symptoms present ≥ 3 months
  • 6 months since onset
  • 1+ of:
    • Postprandial fullness
    • Early satiety
    • Epigastric pain
    • Epigastric burning
  • No structural cause
349.1.0.1.2.2 Subtypes
  • Postprandial Distress Syndrome (PDS): meal-related
  • Epigastric Pain Syndrome (EPS): not meal-related
349.1.0.1.2.3 Workup
  • H. pylori testing
  • PPI trial
  • EGD if alarm features (≥ 60 yo, weight loss, dysphagia, bleeding)
  • Imaging if indicated
349.1.0.1.2.4 Treatment
  • H. pylori eradication (if positive)
  • PPI for upper symptoms
  • Prokinetics (metoclopramide for PDS; cautious — tardive dyskinesia)
  • TCAs / SSRIs for refractory
  • Behavioral / dietary modification
  • Probiotics (some evidence)
349.1.0.1.3 Zollinger-Ellison Syndrome (ZES)
349.1.0.1.3.1 Definition
  • Gastrinoma (usually pancreas, duodenum)
  • Hypergastrinemia → hypersecretion of acid
  • Multiple, refractory, atypical ulcers
349.1.0.1.3.2 Associations
  • MEN1 syndrome (25% of ZES)
  • Spontaneous (75%)
349.1.0.1.3.3 Clinical
  • Multiple ulcers (jejunum, distal duodenum)
  • Refractory to standard therapy
  • Diarrhea (acid + steatorrhea)
  • Weight loss
  • Often metastatic at diagnosis
349.1.0.1.3.4 Diagnosis
  • Serum gastrin (off PPI 1-2 weeks; > 1000 highly suggestive)
  • Gastric pH (must be acidic on testing)
  • Secretin stimulation test
  • Imaging: octreotide scan, MRI, EUS
349.1.0.1.3.5 Treatment
  • High-dose PPI (often BID)
  • Surgical resection if localized
  • Octreotide / lanreotide for unresectable
  • Sunitinib / everolimus for advanced
  • PRRT (Lutathera) for somatostatin receptor + tumors
  • Multidisciplinary

349.1.0.2 🩺 床邊速查

  • PUD: H. pylori most common (globally); NSAID developed
  • DU: pain relieved by food
  • GU: pain worsened by food; all GU need biopsy
  • H. pylori testing: UBT, stool antigen, biopsy (CLO)
  • Treatment: quadruple therapy preferred (clarithromycin resistance ↑); vonoprazan-based emerging
  • Functional dyspepsia: Rome IV; PPI, H. pylori, TCA
  • ZES: MEN1 association; gastrin ↑↑; PPI high-dose + surgery