How Can We Help?
Peptic ulcer disease
Background
Patients with central upper abdominal discomfort related to meals should be considered to have peptic ulceration or non-ulcer dyspepsia once evaluated for ischaemic heart disease or gallbladder pathology (history, examination, ECG, and possibly ultrasound).
In these patients it is reasonable in areas where access to endoscopy is limited to treat empirically for peptic ulcer disease omeprazole 30 mg daily for for a month. If response is good, leave it at that. There is no evidence that waiting a month will jeopardise outcome in patients with gastric malignancies, although clearly if there are warning signs of this there is no point in waiting – go ahead with the scope. Warning signs are:
- vomiting,
- bleeding (or anaemia),
- abdominal mass or weight loss,
- dysphagia1
- Some authors include age (40, 50, or 55 are popular cut-offs)
If symptoms do not settle or if they recur, send for endoscopy. Routine empiric treatment for H pylori prior to endoscopy is probably inappropriate, although there are some authorities who endorse this as a cost-effective practice.
Management of peptic ulcer disease
Treatment of peptic ulcer confirmed on endoscopy:
- Lanzoprazole 30 mg 2x/d for 7 days if a duodenal ulcer and 28 days if a gastric ulcer
- Add amoxicillin 1g 12 hourly and metronidazole 400 mg 12 hourly for 14 days if H pylori positive.
Perspective – predictive value of serological tests for H pylori.
A meta-analysis2 found little difference between kits, with pooled results yielding a sensitivity of 85%, specificity 79%, and LR+ 4.0, LR- 0.2.
Hence in areas of high prevalence serology is not particularly helpful.
Perspective – relative efficacy of H pylori eradication regimens
Although there is some evidence that H pylori may co-exist more amicably in developing countries with lower prevalence of gastric ulcer and malignancies,3 it seems that eradication regimens still influence ulcer recurrence rates in populations where prevalence in naturally high (greater than 60%). Older regimens (cimetidine, amoxicillin, metronidazole) are probably less effective, and in particular metronidazole resistance in the developing world seems to be a problem, although there is some evidence that resolution actually may not be worse in high resistance areas using metronidazole containing regimens.
Perspective – effects of long term PPI use in vulnerable patients
Short term, PPIs are relative safe, however there are growing concerns about their long terms use, particularly in the elderly and malnourished. Potential risks which have been investigated include:4
- Anaemia (reduced iron absorption)
- Fractures (calcium absorption)
- Symptomatic hypomagnesaemia
- Vitamin B12 deficiency
- Infection: risk of both pneumonia and C difficile infection, and, in cirrhotic patients, spontaneous bacterial peritonitis
- Acute interstitial nephritis
Most of this evidence is observational, and of fairly low quality; an overview of systematic reviews found evidence of an association with fracture, acute kidney injury, gastric malignancy, and some infections5
van Zanten SV. Upper gastrointestinal alarms: the 2-week rule. Lancet. 2005;365:2163-4 ↩
CT Loy, LM Irwig, PH Katelaris, et al. Do commercial serological kits for Helicobacter pylori infection differ in accuracy? A meta-analysis. Am J Gastroenterol. 1996;91:1138-44 ↩
Segal I, Ally R, Mitchell H. Helicobacter pylori – an African perspective. Q J Med. 2001; 94: 561-565 ↩
Johnson DA, Oldfield EC. Reported side effects and complications of long-term proton pump inhibitor use: dissecting the evidence. Clin Gastroenterol Hepatol. 2013;11:458-464 ↩
Salvo EM, Ferko NC, Cash SB, et al. Umbrella review of 42 systematic reviews with meta-analyses: the safety of proton pump inhibitors. Aliment Pharmacol Ther. 2021 Jul;54(2):129-143. doi: 10.1111/apt.16407. Epub 2021 Jun 11. PMID: 34114655. ↩