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Management of Peptic Ulcer Disease (PUD) and Ulcer Bleeding1.0 Introduction and Scope1.1 Purpose and Definition of PUDThe 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:Helicobacter pylori infection: The most common cause worldwide, leading to chronic gastritis that alters gastrin and acid physiology.Use of Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) and aspirin: These agents cause both topical epithelial injury and systemic inhibition of prostaglandins, which are essential for mucosal defense (e.g., mucus production, bicarbonate secretion, and mucosal blood flow).Acid hypersecretory states: Conditions such as Zollinger-Ellison syndrome (gastrinoma) lead to marked increases in gastric acid production.Stress-related mucosal disease: Typically seen in critically ill patients (e.g., with burns, trauma, or sepsis) due to mucosal ischemia from systemic hypoperfusion.Accurate initial diagnosis and risk stratification are fundamental to tailoring an effective management plan and preventing serious complications.2.0 Initial Diagnosis and Risk Stratification2.1 Clinical PresentationRecognizing 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 EndoscopyThe 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.Bleeding: The presence of hematemesis (vomiting blood), melena (black, tarry stools), or "coffee-ground" emesis. A brisk upper gastrointestinal bleed may also present with hematochezia.Anemia: Unexplained iron deficiency anemia may be the only sign of chronic, occult blood loss from an ulcer.Weight Loss: Unintentional and significant weight loss is a concerning feature that may suggest an underlying malignancy.Vomiting: Persistent vomiting can indicate gastric outlet obstruction due to ulcer-related scarring or edema.Early Satiety or Dysphagia: A feeling of fullness after eating very little or difficulty swallowing may also point toward obstruction or malignancy.The identification of one or more of these alarm features necessitates a prompt referral for definitive endoscopic evaluation.3.0 Endoscopic Evaluation and Ulcer Classification3.1 Endoscopy Protocol and Biopsy StrategyEndoscopy 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.Gastric Ulcers: All gastric ulcers require biopsy to definitively exclude malignancy. The standard protocol is to obtain samples from at least four quadrants of the ulcer edge.Duodenal Ulcers: Duodenal ulcers are rarely malignant and do not require routine biopsy unless they present with atypical features or fail to heal with appropriate therapy.3.2 Ulcer Classification by AppearanceThe 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 foldsThese visual cues, combined with histological analysis, determine the subsequent management pathway.4.0 Management of Helicobacter pylori-Associated PUD4.1 Diagnostic Testing for H. pyloriAccurate diagnosis and complete eradication of Helicobacter pylori are the most critical steps in managing H. pylori-associated PUD and preventing ulcer recurrence.Urea Breath Test (UBT) & Stool Antigen Test: These noninvasive tests are preferred for initial diagnosis and for confirmation of eradication (test-of-cure) due to their high sensitivity and specificity.Biopsy Urease Test (CLO test) & Histology: These invasive tests are performed during endoscopy. The biopsy urease test provides a rapid presumptive diagnosis, while histology allows for direct visualization of the organism and concurrent assessment of gastritis.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 RegimensSelection of an eradication regimen must be based on current guidelines, local antibiotic resistance patterns, and patient history of macrolide exposure.Preferred Regimen (Bismuth Quadruple Therapy): Components: PPI (twice daily), Bismuth subsalicylate (four times daily), Tetracycline (four times daily), and Metronidazole (three times daily). Duration: 14 days.