USMLE Guide: Peptic Ulcer Disease

Introduction

Peptic Ulcer Disease (PUD) is a common gastrointestinal disorder characterized by the formation of ulcers in the lining of the stomach, duodenum, or esophagus. This USMLE guide aims to provide a comprehensive overview of PUD, including its etiology, clinical presentation, diagnosis, and management.

Etiology

1. Helicobacter pylori infection is the most common cause of PUD. It damages the protective mucosal lining, allowing acid and pepsin to injure the underlying tissues.
2. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin and ibuprofen can also lead to PUD by inhibiting prostaglandin synthesis, reducing mucosal protection, and increasing acid secretion.
3. Stress-related mucosal damage can occur in critically ill patients due to physiological stressors like severe burns, trauma, or major surgery.

Clinical Presentation

1. Epigastric pain is the hallmark symptom of PUD. It is typically described as a burning or gnawing sensation that occurs between meals and may be relieved with food or antacids.
2. Nausea, vomiting, and bloating can occur, especially after meals.
3. Hematemesis (vomiting blood) or melena (black, tarry stools) may indicate bleeding ulcers.
4. Perforation of the ulcer can lead to sudden, severe abdominal pain and signs of peritonitis (e.g., guarding, rebound tenderness).
5. Gastroesophageal reflux disease (GERD) can coexist with PUD, causing heartburn and regurgitation.

Diagnosis

1. Upper gastrointestinal endoscopy is the gold standard for diagnosing PUD. It allows direct visualization of ulcers and the collection of biopsy specimens for H. pylori testing.
2. H. pylori testing: Options include urea breath test, stool antigen test, or serology. Endoscopic biopsies can also be tested for H. pylori.
3. Upper gastrointestinal series (barium swallow) can be considered if endoscopy is contraindicated or unavailable. It may reveal ulcer craters or other abnormalities.
4. Hemoglobin and hematocrit should be checked if gastrointestinal bleeding is suspected.

Management

1. Eradication of H. pylori is the cornerstone of treatment. Triple therapy with a proton pump inhibitor (PPI), clarithromycin, and amoxicillin/metronidazole is the first-line regimen.
2. PPIs are also used to alleviate symptoms and promote ulcer healing by reducing gastric acid secretion.
3. Avoidance of NSAIDs is crucial, especially in patients with a history of PUD. If NSAID use is necessary, adding a PPI or misoprostol for mucosal protection is recommended.
4. Lifestyle modifications such as smoking cessation and reducing alcohol consumption can help prevent ulcer recurrence.
5. Complications such as bleeding or perforation require immediate medical or surgical intervention, depending on the severity.
6. Follow-up endoscopy is recommended to confirm ulcer healing and check for H. pylori eradication.

Remember to consider potential drug interactions and adverse effects when prescribing medications for PUD treatment.

Conclusion

Peptic Ulcer Disease is a common gastrointestinal disorder with various etiologies and clinical presentations. Prompt diagnosis through endoscopy and appropriate management, including H. pylori eradication and symptom relief, can lead to successful outcomes. Understanding the pathophysiology, diagnostic strategies, and treatment options is essential for USMLE success and clinical practice.