Management of Peptic Ulcer Disease (PUD) and Ulcer Bleeding
1.0 Introduction and Scope
1.1 Purpose and Definition of PUD
The strategic management of Peptic Ulcer Disease (PUD) is critical to ensuring optimal patient outcomes and efficient resource utilization. This protocol establishes a standardized, evidence-based framework for the diagnosis, risk stratification, and treatment of PUD. Adherence to this protocol is intended to reduce recurrence rates, minimize complications, and promote consistent care across all clinical settings.
Peptic Ulcer Disease is defined as a discrete break in the gastric or duodenal mucosa that penetrates through the muscularis mucosae. This is a crucial distinction from gastritis or gastropathy, which represent more superficial mucosal irritation or microscopic injury without a definitive, penetrating defect. PUD arises when mucosal defense mechanisms are overwhelmed by aggressive factors such as luminal acid and pepsin.
The primary etiologies of PUD include:
Accurate initial diagnosis and risk stratification are fundamental to tailoring an effective management plan and preventing serious complications.
2.0 Initial Diagnosis and Risk Stratification
2.1 Clinical Presentation
Recognizing the varied clinical presentations of PUD is critical for timely diagnosis and intervention. While epigastric pain—often described as a "burning" or "gnawing" sensation—is the hallmark symptom, its relationship to meals can suggest the ulcer's location. It is crucial to note that PUD may be clinically silent until a complication occurs, particularly in elderly patients and chronic NSAID users.
| Duodenal Ulcer | Gastric Ulcer
| Pain is classically relieved by meals. | Pain is classically worsened by meals, which can lead to a fear of eating, early satiety, and subsequent weight loss.
| Pain often returns 2-3 hours after eating. | More common in older patient populations.
| Nocturnal pain is common. |
| More common in younger patient populations. |
2.2 Alarm Features Mandating Urgent Endoscopy
The presence of "alarm features" signals potential complications and mandates urgent endoscopic evaluation to establish a definitive diagnosis and rule out serious underlying pathology. It is critical to identify these features upon initial patient assessment.
The identification of one or more of these alarm features necessitates a prompt referral for definitive endoscopic evaluation.
3.0 Endoscopic Evaluation and Ulcer Classification
3.1 Endoscopy Protocol and Biopsy Strategy
Endoscopy is the gold standard for the diagnosis of PUD. It provides direct visualization of the mucosa, allowing for definitive diagnosis, tissue sampling to determine etiology and exclude malignancy, and therapeutic intervention in cases of bleeding. The biopsy strategy is determined by the ulcer's location.
3.2 Ulcer Classification by Appearance
The endoscopic appearance of an ulcer provides crucial information regarding its potential for malignancy. Clinicians must be able to differentiate benign and malignant characteristics to guide biopsy and follow-up strategies.
| Benign Appearance | Malignant Appearance
| Smooth, round, or oval shape | Irregular, "heaped-up," or rolled margins
| "Punched-out" crater | Necrotic base
| Radiating mucosal folds that reach the ulcer edge | Eccentric or interrupted mucosal folds
These visual cues, combined with histological analysis, determine the subsequent management pathway.
4.0 Management of Helicobacter pylori-Associated PUD
4.1 Diagnostic Testing for H. pylori
Accurate diagnosis and complete eradication of Helicobacter pylori are the most critical steps in managing H. pylori-associated PUD and preventing ulcer recurrence.
Protocol Directive: To avoid false-negative results, patients must discontinue Proton Pump Inhibitors (PPIs) for at least 2 weeks and bismuth-containing compounds or antibiotics for at least 4 weeks prior to testing.
4.2 Eradication Regimens
Selection of an eradication regimen must be based on current guidelines, local antibiotic resistance patterns, and patient history of macrolide exposure.
