Overview
Acute Gastritis and Peptic Ulcer Disease
Quick Reference
Critical Alerts
- Perforated ulcer is a surgical emergency: Free air, peritonitis
- GI bleeding from ulcer can be life-threatening: Melena, hematemesis, hemodynamic instability
- NSAIDs and H. pylori are main causes: Address both
- PPI therapy is cornerstone of treatment: IV for bleeding, oral for uncomplicated
- Endoscopy for high-risk bleeding: Within 24 hours
Red Flags
| Finding | Concern | Action |
|---|---|---|
| Hematemesis/Melena | Active GI bleed | IV PPI, resuscitation, GI consult |
| Rigid abdomen | Perforation | CT, surgical consult |
| Free air on imaging | Perforation | Emergent surgery |
| Epigastric pain + hypotension | Bleeding or perforation | Resuscitation, imaging |
| Weight loss, anemia | Malignancy | EGD |
Emergency Treatments
| Condition | Treatment |
|---|---|
| Uncomplicated gastritis/PUD | PPI (omeprazole 20-40 mg daily) + H. pylori treatment if positive |
| Bleeding ulcer | IV PPI (pantoprazole 80 mg bolus → 8 mg/hr) + EGD within 24h |
| Perforated ulcer | NPO, IV fluids, IV antibiotics, emergent surgery |
Definition
Overview
Gastritis is inflammation of the gastric mucosa. Peptic ulcer disease (PUD) refers to ulcers of the stomach (gastric ulcer) or duodenum (duodenal ulcer). The most common causes are H. pylori infection and NSAID use. Complications include bleeding and perforation, which are medical and surgical emergencies respectively.
Classification
By Location:
| Type | Location |
|---|---|
| Gastric ulcer | Stomach |
| Duodenal ulcer | Duodenum |
By Etiology:
| Cause | Notes |
|---|---|
| H. pylori | Most common cause of PUD |
| NSAIDs | Direct mucosal injury, prostaglandin inhibition |
| Stress ulcers | ICU patients, burns, trauma |
| Other | Zollinger-Ellison, malignancy |
Epidemiology
- Prevalence: 5-10% lifetime risk of PUD
- H. pylori: Responsible for 70-80% of duodenal ulcers, 50-60% of gastric ulcers
- NSAID use: Second most common cause
- Complications: 20-25% of PUD patients develop complications (bleeding, perforation)
Etiology
H. pylori:
- Gram-negative spiral bacterium
- Colonizes gastric mucosa
- Causes chronic gastritis → Ulceration
NSAIDs:
- Inhibit prostaglandin synthesis
- Reduce mucosal defenses
- Direct topical injury
Other Causes:
| Cause | Notes |
|---|---|
| Stress ulcers | Critical illness, mechanical ventilation, burns |
| Zollinger-Ellison syndrome | Gastrinoma → Excess acid production |
| Malignancy | Gastric cancer can ulcerate |
| Corticosteroids | When combined with NSAIDs |
Pathophysiology
Mechanism
Imbalance of Aggressive and Protective Factors:
| Aggressive | Protective |
|---|---|
| Gastric acid | Mucus layer |
| Pepsin | Bicarbonate secretion |
| H. pylori | Prostaglandins |
| NSAIDs | Mucosal blood flow |
H. pylori:
- Produces urease → Neutralizes gastric acid locally
- Causes chronic inflammation
- Disrupts mucosal defense
NSAIDs:
- Inhibit COX-1 → Decrease prostaglandins
- Reduce mucus and bicarbonate secretion
- Impair mucosal blood flow
Clinical Presentation
Symptoms
| Symptom | Gastric Ulcer | Duodenal Ulcer |
|---|---|---|
| Epigastric pain | Worsened by food | Relieved by food |
| Timing | 15-30 min after eating | 2-3 hours after eating, nocturnal |
| Nausea/Vomiting | Common | Less common |
| Weight loss | May occur | Less common |
| Bloating | Common | Common |
Symptoms of Complications:
| Finding | Complication |
|---|---|
| Hematemesis, melena | Bleeding |
| Sudden severe abdominal pain | Perforation |
| Vomiting + distension | Gastric outlet obstruction |
History
Key Questions:
Physical Examination
| Finding | Significance |
|---|---|
| Epigastric tenderness | Common in gastritis/PUD |
| Pallor | Anemia from chronic or acute bleeding |
| Tachycardia, hypotension | Acute bleeding |
| Rigid abdomen, rebound | Perforation |
| Positive fecal occult blood | GI bleeding |
Epigastric pain character, timing, relation to food
Common presentation.
NSAID or aspirin use
Common presentation.
Prior H. pylori treatment
Common presentation.
Hematemesis, melena, black stools
Common presentation.
Weight loss
Common presentation.
Prior ulcer or GI bleeding
Common presentation.
Alcohol use, smoking
Common presentation.
Red Flags
Complications
| Finding | Concern | Action |
|---|---|---|
| Hematemesis or melena | Upper GI bleeding | IV PPI, resuscitation, EGD |
| Rigid abdomen | Perforation | CT, surgery |
| Free air on imaging | Perforation | Emergent surgery |
| Hypotension, tachycardia | Hemorrhagic shock | Resuscitation |
| Persistent vomiting + distension | Gastric outlet obstruction | NG decompression, EGD |
Differential Diagnosis
Other Causes of Epigastric Pain
| Diagnosis | Features |
|---|---|
| GERD | Heartburn, regurgitation |
| Acute pancreatitis | Radiates to back, elevated lipase |
| Cholecystitis | RUQ pain, Murphy's sign |
| MI (inferior) | Risk factors, ECG changes |
| Gastric cancer | Weight loss, early satiety |
| Functional dyspepsia | Chronic symptoms, negative workup |
Diagnostic Approach
Clinical Diagnosis
- Gastritis and PUD often diagnosed clinically
- EGD for confirmation and H. pylori testing
H. pylori Testing
Non-Invasive:
| Test | Notes |
|---|---|
| Urea breath test | High sensitivity and specificity; avoid PPIs 2 weeks prior |
| Stool antigen test | Useful for diagnosis and test of cure |
| Serology (IgG) | Indicates exposure, not active infection |
Invasive (EGD-Based):
| Test | Notes |
|---|---|
| Rapid urease test (CLO) | Biopsy-based |
| Histology | Gold standard |
| Culture | Antibiotic susceptibility testing |
Imaging
Abdominal X-Ray (Upright):
- Free air under diaphragm = Perforation
CT Abdomen:
- Sensitive for perforation, abscess, other pathology
Endoscopy (EGD)
Indications:
| Indication | Urgency |
|---|---|
| Active upper GI bleeding | Within 24 hours |
| Alarm symptoms (weight loss, anemia, vomiting) | Urgent |
| Refractory symptoms despite PPI | Elective |
| Gastric ulcer | Rule out malignancy |
Treatment
Principles
- Acid suppression: PPI is cornerstone
- H. pylori eradication: If positive
- Stop NSAIDs: If possible
- Address complications: Bleeding, perforation
Acid Suppression
Proton Pump Inhibitors (PPIs):
| Agent | Dose |
|---|---|
| Omeprazole | 20-40 mg daily |
| Pantoprazole | 40 mg daily |
| Esomeprazole | 20-40 mg daily |
Duration: 4-8 weeks for ulcer healing
H. pylori Eradication
First-Line Triple Therapy:
| Component | Dose | Duration |
|---|---|---|
| PPI | BID | 14 days |
| Clarithromycin | 500 mg BID | 14 days |
| Amoxicillin | 1 g BID | 14 days |
Alternative (Penicillin Allergy):
| Component | Dose | Duration |
|---|---|---|
| PPI | BID | 14 days |
| Clarithromycin | 500 mg BID | 14 days |
| Metronidazole | 500 mg BID | 14 days |
Quadruple Therapy (Bismuth):
| Component | Dose | Duration |
|---|---|---|
| PPI | BID | 14 days |
| Bismuth subsalicylate | 524 mg QID | 14 days |
| Metronidazole | 500 mg TID | 14 days |
| Tetracycline | 500 mg QID | 14 days |
NSAID-Related Ulcer
- Discontinue NSAID if possible
- PPI therapy for healing
- If NSAID must be continued: Use lowest effective dose + PPI co-therapy
- Consider COX-2 selective NSAID (lower GI risk)
Bleeding Ulcer
| Intervention | Details |
|---|---|
| Resuscitation | IV fluids, blood transfusion if needed |
| IV PPI | Pantoprazole 80 mg bolus → 8 mg/hr infusion × 72 hours |
| EGD | Within 24 hours for diagnosis and hemostasis |
| Transfusion threshold | Hgb <7-8 g/dL (general guideline) |
Endoscopic Hemostasis:
- Injection (epinephrine)
- Thermal coagulation
- Clips
Perforated Ulcer
| Intervention | Details |
|---|---|
| NPO | Bowel rest |
| NG tube | Decompression |
| IV fluids | Resuscitation |
| IV antibiotics | Broad-spectrum (pip-tazo or ceftriaxone + metronidazole) |
| Emergent surgery | Primary closure or definitive surgery |
Disposition
Discharge Criteria
- Uncomplicated gastritis/PUD
- Pain controlled
- Able to tolerate oral PPI
- No signs of bleeding or perforation
- Follow-up arranged
Admission Criteria
- Active GI bleeding
- Perforation
- Unable to tolerate oral intake
- Severe pain not controlled
- High-risk features (hemodynamic instability, comorbidities)
Referral
| Indication | Referral |
|---|---|
| Gastric ulcer | EGD to rule out malignancy |
| Refractory symptoms | GI |
| Bleeding ulcer | GI (endoscopy) |
| Perforation | Surgery |
Follow-Up
| Situation | Follow-Up |
|---|---|
| Uncomplicated PUD | PCP in 2-4 weeks |
| H. pylori treated | Test of cure 4 weeks after completing therapy |
| Gastric ulcer | Repeat EGD in 8-12 weeks to confirm healing |
Patient Education
Condition Explanation
- "You have inflammation or ulcers in your stomach lining."
- "This is often caused by a bacteria called H. pylori or by medications like ibuprofen."
- "A medication called a PPI will help heal the ulcer by reducing acid."
Home Care
- Take PPI as directed
- Complete H. pylori treatment if prescribed
- Avoid NSAIDs (ibuprofen, naproxen, aspirin unless prescribed)
- Avoid alcohol and smoking
- Eat smaller, more frequent meals
Warning Signs to Return
- Vomiting blood or "coffee ground" material
- Black, tarry stools
- Sudden severe abdominal pain
- Dizziness or fainting
- Worsening symptoms despite treatment
Special Populations
Elderly
- Higher risk of complications (bleeding, perforation)
- Be cautious with NSAIDs
- Lower threshold for EGD
NSAID Users
- Always consider PUD
- Co-prescribe PPI if NSAIDs necessary
- Consider COX-2 selective agents
Patients on Anticoagulation
- Higher bleeding risk
- Balance anticoagulation needs with GI risk
- PPI co-therapy if on anticoagulation + NSAID
Quality Metrics
Performance Indicators
| Metric | Target | Rationale |
|---|---|---|
| H. pylori testing for PUD | >0% | Identify treatable cause |
| NSAID cessation counseled | 100% | Prevent recurrence |
| IV PPI for bleeding ulcer | 100% | Guideline adherence |
| EGD within 24h for bleeding | >0% | Reduce rebleeding risk |
Documentation Requirements
- NSAID and aspirin use
- H. pylori testing or treatment
- PPI prescribed
- Red flag assessment
- Bleeding status
- Follow-up plan
Key Clinical Pearls
Diagnostic Pearls
- Duodenal ulcer: Pain relieved by food: Classic
- Gastric ulcer: Pain worsened by food: And may have weight loss
- H. pylori is most common cause: Test and treat
- NSAIDs are second most common: Stop if possible
- Gastric ulcer = EGD to rule out cancer: Always
- Free air = Perforation: Emergent surgery
Treatment Pearls
- PPIs are cornerstone: For acid suppression
- Triple therapy for H. pylori: PPI + clarithromycin + amoxicillin × 14 days
- IV PPI for bleeding ulcer: High-dose infusion
- Stop NSAIDs: And consider COX-2 selective if must use
- EGD within 24 hours for bleeding: Diagnosis and hemostasis
- Test of cure after H. pylori treatment: Confirm eradication
Disposition Pearls
- Uncomplicated gastritis/PUD can be discharged: With PPI
- Admit for bleeding or perforation: Life-threatening
- Repeat EGD for gastric ulcers: Confirm healing, rule out cancer
- Follow-up essential: H. pylori cure, symptom resolution
References
- Chey WD, et al. ACG Clinical Guideline: Treatment of Helicobacter pylori Infection. Am J Gastroenterol. 2017;112(2):212-239.
- Laine L, et al. Management of patients with ulcer bleeding. Am J Gastroenterol. 2012;107(3):345-360.
- Malfertheiner P, et al. Management of Helicobacter pylori infection—the Maastricht V/Florence Consensus Report. Gut. 2017;66(1):6-30.
- Lau JY, et al. Endoscopy for upper gastrointestinal bleeding. N Engl J Med. 2010;362(16):1493-1502.
- Ramakrishnan K, Salinas RC. Peptic Ulcer Disease. Am Fam Physician. 2007;76(7):1005-1012.
- Sverdén E, et al. Use of proton pump inhibitors and the risk of gastric cancer. JAMA Oncol. 2018;4(4):e175855.
- NICE Guideline. Gastro-oesophageal reflux disease and dyspepsia in adults. 2014.
- UpToDate. Peptic ulcer disease: Treatment and secondary prevention. 2024.