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Peptic Ulcer- Clinical Manifestations, Presenting Symptoms, Alarming features and Investigating Tests!

 PEPTIC ULCER

Clinical Manifestations:

  • Upper abdominal pain; occurring 1-3hour after meals and relieved by food or antacids in the classic symptom of peptic-ulcer disease.
  • Anorexia
  • Weight loss
  • Nausea
  • Vomiting
  • Heartburn
  • Hemorrhage
  • Chronic-iron deficiency anemia
  • Pyloric stenosis
  • Perforations
  • In the elderly, the presentation is more likely to be silent and gastro-intestinal bleeding may be the first clinical sign of disease.

Patient Assessment:

Presenting symptoms of dyspepsia require careful assessment to judge the risk of serious disease or to provide appropriate symptomatic treatment.

     1.Reflux-like dyspepsia:

  • Heartburn plus dyspepsia
  • Acid regurgitation plus dyspepsia

      2. Ulcer-like dyspepsia:

  •  Localized epigastric pain.
  • Pain when hungry
  • Pain relieved by food.
  • Pain relieved by antacids or acid-reducing drugs.
  • Pain that wakens the patient from sleep
  • Pain with remission and relapse

     3. Dysmotility-like Dyspepsia:

  • Upper abdominal discomfort (pain not dominant)
  • Early satiety
  • Postprandial fullness
  • Nausea
  • Vomiting
  • Bloating in the upper abdomen (No visible distention)
  • Upper abdominal discomfort often aggravated by food

      4. Unspecified dyspepsia


Drugs Causing Dyspepsia:

  1. Antibiotics
  2. Bisphosphonates
  3. Calcium Channel Blockers
  4. Corticosteroids
  5. Drugs with Anti-muscarinic effects e.g: Tricyclic Antidepressants
  6. Iron
  7. Nitrates
  8. NSAIDs including Aspirin.
  9. Potassium Chloride
  10. Theophylline

Alarming Features:

  • Dysphagia (medical term for difficulty in swallowing)
  • Pain on swallowing
  • Unintentional weight loss
  • Gastro-intestinal bleeding or Anemia
  • Persistent vomiting
  • On NSAIDs or Warfarin

Investigations:

1. Endoscopy: 

  • Endoscopy is generally the investigation of choice for diagnosing peptic ulcer. The procedure is sensitive, specific and safe. However, it is also invasive and expensive.
  • Endoscopic investigations should be undertaken in patients with alarming features and in those over 55 years who present with unexplained or persistent symptoms of dyspepsia.
  • Biopsies may be taken to exclude malignancy and uncommon lesions such as Crohn's Disease.
  • Patients with upper gastro-intestinal bleeding have traditionally undergone endoscopy.
  • Most patients do not require endoscopy and in those at low risk, endoscopy and admission to hospital can be avoided by application of Scoring system. The most widely used is the ROCKALL RISK Scoring System (which includes endoscopic findings to predict poor outcome).

2.Radiology:

  • Double-contrast Barium Radiography should detect 80% of peptic ulcers.
  • A Gastrograffin meal is used to diagnose peptic perforation in patients presenting with an acute abdomen, if a plain abdominal X-ray is not diagnostic.

3. H.Pylori Detection:

There are several methods of detecting H.Pylori infection. They include non-invasive tests such as;

  • Serological tests 
  • Urea Breath Tests
  • Stool Antigen Tests
  • Invasive Tests

  1. Serological tests: Is used to detect antibodies, (anti-H.Pylori IgG antibodies) but are not able to distinguish between active or previous exposure to infection.
  2. Urea Breath Tests: have a sensitivity and specificity over 90% and are accurate for both initial diagnosis and confirmation of eradication. The breath test is based on the principle of urease activity in stomach of infected individuals hydrolyses urea to form ammonia and Carbon dioxide. The test contains carbon-labelled urea which, when hydrolyzed results in production of labelled Carbon dioxide which appears in the breath test. The breath test is preferable and more convenient.
  3. Stool Antigen Test: uses an enzyme immunoassay to detect H.Pylori antigen i stool. This test has a sensitivity and specificity of over 90% and can be used in initial diagnosis and also to confirm eradication.
  4. Invasive tests: require gastric antral biopsies; include urease tests, histology, and culture. Of these, the biopsy urease test is widely used. Agar-based biopsy urease tests are designed to be read at 24hour. Strip-based biopsy urease tests are to be read at 2 hours.
  5. The fecal occult Blood test: is not specific for or sensitive to detection of NSAID-induced gastric damage. A full blood count may provide evidence of blood loss from peptic ulcer.

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