18. Conclusion

PUD is a common clinical problem. The two most important risk factors are H. pylori infection and NSAIDs. Patients may present with dyspepsia or may remain asymptomatic. Endoscopy is the gold standard for the diagnosis of PUD. But as it is not possible to endoscope so many dyspeptic patients, there are some non-endoscopic approaches depending on the prevalence of H. pylori infection in the population. But ACG and CAG recommend EGD to be done in patients ≥60 years of age presenting with dyspepsia irrespective of alarm features. Bismuth quadruple therapy or concomitant therapy should be considered as the first-line therapy against H. pylori infection. In patients with PUD, eradication of H. pylori infection (if positive) should be confirmed ≥4 weeks after completion of therapy. PPI, H2RA, misoprostol, and sucralfate are the main agents used for healing of PU. Surveillance endoscopy is recommended in certain gastric ulcers. PUD can be complicated by bleeding, perforation, penetration, and gastric outlet obstruction. Patients with bleeding peptic ulcer should be evaluated, resuscitated, and started on intravenous/infusion of PPI. Diagnostic and therapeutic endoscopy should be done to achieve endoscopic hemostasis. If endoscopic therapy fails, the next step will be TAE or surgery. The mortality for peptic ulcer bleeding still remains high.

Author details

Peptic Ulcer Disease

DOI: http://dx.doi.org/10.5772/intechopen.86652

Monjur Ahmed

17

Jefferson University Hospital, Philadelphia, USA

provided the original work is properly cited.

\*Address all correspondence to: monjur.ahmed@jefferson.edu

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

Peptic Ulcer Disease DOI: http://dx.doi.org/10.5772/intechopen.86652

16. Penetration

Digestive System - Recent Advances

surgical intervention.

18. Conclusion

remains high.

16

17. Gastric outlet obstruction (GOO)

treatment need endoscopic dilation or surgery [82, 83].

When the ulcer crater erodes through the gastric wall or intestinal wall into the surrounding structure but there is no free perforation or leakage of luminal contents

It occurs in less than 5% cases of PUD. Duodenal ulcer and pyloric channel ulcer

are generally associated with GOO. Pathophysiologically, reversible causes like inflammation, edema, spasm, and pyloric dysmotility and irreversible cause like fibrosis may lead to GOO. Patients present with nausea, vomiting, early satiety, epigastric pain, and weight loss. Patients may develop severe dehydration, azotemia, hyponatremia, and hypochloremic and hypokalemic metabolic alkalosis with paradoxical aciduria due to prolonged vomiting. First, the fluid and electrolyte deficit should be corrected. Gastric contents should be removed by large-bore Ewald tube, and then intermittent nasogastric tube suction should be continued for a few days. Many cases of GOO due to PUD have reversible components which may respond to this conservative treatment. Patients not responding to the conservative

PUD is a common clinical problem. The two most important risk factors are H. pylori infection and NSAIDs. Patients may present with dyspepsia or may remain asymptomatic. Endoscopy is the gold standard for the diagnosis of PUD. But as it is not possible to endoscope so many dyspeptic patients, there are some non-endoscopic approaches depending on the prevalence of H. pylori infection in the population. But ACG and CAG recommend EGD to be done in patients ≥60 years of age presenting with dyspepsia irrespective of alarm features. Bismuth quadruple therapy or concomitant therapy should be considered as the first-line therapy against H. pylori infection. In patients with PUD, eradication of H. pylori infection (if positive) should be confirmed ≥4 weeks after completion of therapy. PPI, H2RA, misoprostol, and sucralfate are the main agents used for healing of PU. Surveillance endoscopy is recommended in certain gastric ulcers. PUD can be complicated by bleeding, perforation, penetration, and gastric outlet obstruction. Patients with bleeding peptic ulcer should be evaluated, resuscitated, and started on intravenous/infusion of PPI. Diagnostic and therapeutic endoscopy should be done to achieve endoscopic hemostasis. If endoscopic therapy fails, the next step will be TAE or surgery. The mortality for peptic ulcer bleeding still

into the peritoneal cavity, it is called penetration [80]. The pancreas is the commonest site of penetration. Other sites of penetration include the omentum, biliary tract, liver, colon, mesocolon, and blood vessels. Patients may notice change in pattern of abdominal pain, i.e., pain not being relieved by taking food or medication. Diagnosis is confirmed by CT with contrast which may show loss of fascial plane between the gastric wall or intestinal wall and the surrounding structure, band of soft tissue density between them, ulcer crater, sinus tract, and enlargement of head of the pancreas in case of penetration into the pancreas [81]. Treatment is
