Gastroenterology & Internal Medicine & Family Medicine
Peptic Ulcer Disease
Gastroduodenal ulcer (UGD) is a localized loss of the gastric or duodenal lining that extends beyond the muscularis mucosae, resulting from an imbalance between aggressive factors (hydrochloric acid + pepsin + Helicobacter pylori + AINS + aspirin) and mucosal defense mechanisms (mucus + bicarbonate + cell turnover + prostaglandins + vascularization). With a lifelong prevalence of 5% to 10% in developed countries %, PUD remains one of the most frequent gastrointestinal conditions—although its incidence has considerably decreased since the discovery of the role of'H. pylori by Marshall and Warren (Nobel laureates 2005) and the generalization of eradication treatments. The two main causes—which together account for more than 90 % of cases—are infection with Helicobacter pylori (bacille à Gram négatif microaérophile hélicoïdal colonisant la muqueuse gastrique chez 50 % de la population mondiale + mais causant un ulcère chez 10–15 % des porteurs) + et la prise d'anti-inflammatoires non stéroïdiens (AINS) et d'aspirine (inhibition des COX-1 et COX-2 → réduction des prostaglandines cytoprotectrices → altération de la barrière muqueuse). L'ulcère duodénal (UD) est plus fréquent que l'ulcère gastrique (UG) + et survient typiquement chez des patients plus jeunes + avec une hypersécrétion acide + alors que l'ulcère gastrique — dont environ 5 % des cas cachent un cancer gastrique — survient plus souvent chez les patients plus âgés sous AINS. La distinction clinique est importante : la douleur épigastrique de l'ulcère duodénal est typiquement soulagée par les repas + alors que celle de l'ulcère gastrique est aggravée par les repas.
Clinical presentation
- Duodenal ulcer (DU) - typical presentation: Epigastric pain, burning or cramping, occurring 2-3 hours after meals (hunger pain), nocturnal (waking between 1 am and 3 am - highly suggestive), relieved by meals, antacids, and PPIs, meal-related, associated with acid hypersecretion, periodic (bouts of a few weeks interspersed with remissions).
- Gastric ulcer (GU) - often atypical presentation: epigastric pain + sometimes worsened by meals (unlike peptic ulcer disease) + nausea + anorexia + weight loss + more often asymptomatic (especially NSAID ulcers - «silent» until complication) + presenting complication can be hemorrhage or perforation
- Alarm symptoms requiring urgent endoscopy: Hematuria (vomiting blood) + melena (tarry black stools) + dysphagia + odynophagia + significant weight loss + unexplained iron-deficiency anemia + palpable epigastric mass + age > 55–60 years with new symptoms
- Asymptomatic ulcer ( «silent» PUD ) : Frequent under NSAIDs → revealed by a complication (hemorrhage + perforation) → reason why any high-risk patient on NSAIDs should receive a gastroprotective PPI
Diagnosis
- Gastroscopy (EGD - esophagogastroduodenoscopy): Reference examination + direct visualization + biopsies + ulcer characterization (size + location + base + edges) + systematic biopsies of any gastric ulcer (search for malignancy + 5 %of gastric ulcers are excavated cancers) + rapid urease test on biopsy (H. pylori detection + 90–95 % sensitivity) + NOT essential for uncomplicated duodenal ulcer in young patient without alarm symptoms if H. pylori confirmed by non-invasive test
- Urea Breath Test (UBT): Reference non-invasive test for screening and confirmation of H. pylori eradication → 95% sensitivity % + 95% specificity % + patient must have stopped PPIs for ≥ 2 weeks + antibiotics for ≥ 4 weeks + bismuth for ≥ 4 weeks → test of choice for confirmation of eradication (4 weeks after end of treatment)
- H. pylori fecal antigens: Non-invasive test alternative to breath test + similar sensitivity and specificity + useful if breath test is unavailable
- H. pylori serology (anti-H. pylori IgG): of little practical use because positive even after eradication + does not distinguish between an active infection and an old infection → DO NOT use to confirm eradication
H. pylori eradication treatment
| Diet | Medicines | Duration | Eradication rate |
|---|---|---|---|
| Triple standard therapy (first-line if clarithromycin resistance <15% %) | IPP (omeprazole 20 mg x 2/day or equivalent) + clarithromycin 500 mg x 2/day + amoxicillin 1 g x 2/day | 14 days | 75–85 % (10 jours) → 80–90 % (14 jours — recommandé) |
| Quadruple therapy with bismuth (alternative first-line or if high clarithromycin resistance) | IPP + bismuth subcitrate + metronidazole 500 mg 3 times/day + tetracycline 500 mg 4 times/day (PYLERA® = fixed combination) | 10-14 days | 85–95 % — treatment of choice if clarithromycin resistance is suspected or proven |
| Adjunctive therapy (first-line alternative) | IPP + clarithromycin 500 mg × 2/day + amoxicillin 1 g × 2/day + metronidazole 500 mg × 2/day — all 4 taken simultaneously | 14 days | 85–92 % — partially bypasses clarithromycin resistance |
| Rescue therapy (2nd line if failed) | IPP + levofloxacin 500 mg once daily + amoxicillin 1 g twice daily (if clarithromycin resistance) + or quadruple with bismuth if not used in first-line | 14 days | Variable — ideally an antibiogram on culture before the second line |
PPI in NSAID-induced ulcer prevention
- Indications for PPIs for gastroprotection in patients taking NSAIDs: Age > 65 years + history of ulcer or digestive complications + high-dose NSAIDs or NSAID combinations + NSAID combination + anticoagulants or antiplatelets + NSAID combination + corticosteroids + positive H. pylori → systematic PPI for the entire duration of NSAID treatment
- Low-dose aspirin (antiplatelet) Ulcer and possible digestive bleeding even at 75–100 mg/day → PPI recommended if history of ulcer or in patients at high digestive risk
- Selective COX-2 inhibitors (coxibs — celecoxib + etoricoxib): less ulcerogenic than non-selective NSAIDs → but residual risk of ulcer + especially if combined with aspirin or anticoagulants → PPIs depending on risk profile
- Duration of permanent partial disability: for the entire duration of NSAID use + if chronic NSAID use → chronic PPI
Complications
- Upper digestive bleeding (most common - 15-20 % of PUD): hematemesis (vomiting red or coffee-ground blood) + melena (foul-smelling, tarry black stools) + or hematochezia if massive bleeding + hemorrhagic shock + high-dose IV PPI (omeprazole 80 mg bolus + 8 mg/h infusion) + urgent EGD ((24 h stable + <12 h unstable) + endoscopic hemostasis (adrenaline injection + thermocoagulation + hemostatic clip) + Forrest classification (re-bleeding risk)
- Perforation (surgical emergency — 5 % of ED visits): Sudden + intense + «stabbing» abdominal pain + pneumoperitoneum (air under the diaphragm on upright chest X-ray) + abdominal guarding + peritonitis → emergency laparotomy or laparoscopy + suture of perforation + peritoneal lavage
- Pyloric stenosis (late complication - chronic recurrent duodenal ulcer): late postprandial vomiting + food + projectile + weight loss + dehydration + hypokalemic alkalosis (vomiting of HCl) → endoscopic dilatation + or surgery
- Malignant degeneration (gastric ulcer only): 5% of gastric ulcers are cancers → systematic biopsies of any gastric ulcer + endoscopic healing control at 6–8 weeks
ℙ️
Confirmation of H. pylori eradication is essential after any eradication treatment. It should be performed using a non-invasive test (urea breath test or fecal antigen test) at least 4 weeks after the end of antibiotics and at least 2 weeks after stopping PPIs. PPIs can interfere with tests by artificially reducing the bacterial load. IgG anti-H. pylori serology remains positive long after eradication and cannot be used to confirm eradication.
Digestive emergency — call 911
Call 911 or go to the emergency room immediately if vomiting blood + tarry black stools + sudden «stabbing» abdominal pain + or signs of shock (paleness + sweating + rapid heart rate + low blood pressure) appear — these signs suggest upper gastrointestinal bleeding or a perforated ulcer requiring urgent endoscopic or surgical management. For the diagnosis and outpatient treatment of uncomplicated PUD, Clinique Omicron offers medical consultations at its service points in Quebec and via telemedicine. To make an appointment, visit cliniqueomicron.ca.
Consult at Clinique Omicron
Clinique Omicron's physician associates and nurse practitioners (NPs) prescribe the Urea Breath Test (UBT) or fecal antigen test for H. pylori screening, initiate triple or quadruple therapy based on local resistance profiles, confirm eradication at 4 weeks post-antibiotics, prescribe gastroprotective PPIs in at-risk patients on NSAIDs, refer to gastroenterology for EGD if alarm symptoms are present or if gastric ulcer (biopsies for malignancy), and ensure healing follow-up. Consultations are available at several service points in Quebec and via telemedicine. To book an appointment, visit cliniqueomicron.ca.
The content of this page is for informational purposes only and does not replace the advice of a doctor or gastroenterologist. Any gastric ulcer must undergo systematic biopsies and endoscopic healing control at 6-8 weeks to rule out malignancy. Anti-H. pylori IgG serology should not be used to confirm eradication—use the breath test or fecal antigens 4 weeks after completion of treatment.
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