Procedures

Table 2. Tests Used in the Diagnosis of Peptic Ulcer
Test	Comments
EGD ______________________	Indicated in patients with evidence of bleeding, weight loss, chronicity, or persistent vomiting; those whose symptoms do not respond to medications; and those older than 55 years More than 90 % sensitivity and specificity in diagnosing gastric and duodenal ulcers and cancers
Barium or Gastrografin contrast radiography (double-contrast hypotonic duodenography)	Indicated when endoscopy is unsuitable or not feasible, or if complications such as gastric outlet obstruction suspected Diagnostic accuracy increases with extent of disease; 80 to 90 % sensitivity in detecting duodenal ulcers
Helicobacter pylori testing
Serologic ELISA _____________________	Useful only for initial testing (sensitivity, 85 %; specificity, 79 %); cannot be used to confirm eradication
Urea breath test ______________________	More expensive, Sensitivity, 95 to 100 %; specificity, 91 to 98 %; can be used to confirm eradication PPI therapy should be stopped for 2 weeks before test
Stool antigen test ______________________	Inconvenient but accurate (sensitivity 91 to 98 %; specificity 94 to 99%), Can be used to confirm eradication
Urine-based ELISA and rapid urine test	Sensitivity, 70 to 96 %; specificity, 77 to 85 % Cannot be used to confirm eradication
Endoscopic biopsy	Culture (sensitivity, 70 to 80 %; specificity, 100 %), histology (sensitivity, > 95 %; specificity, 100 %), rapid urease (CLO) test (sensitivity, 93 to 97 %; specificity, 100 %)
EGD = esophagogastroduodenoscopy; ELISA= enzyme-linked immunosorbent assay; PPI= proton pump inhibitor; CLO= Campylobacter-like organism.

Differential diagnosis of PUD and gastritis, gastric cancer, pancreatitis etc.

Management.

Primary (first-line) H. pylori eradication therapy: H+/K+ ATPase inhibitors (omeprazole), amoxicillin or metronidazole, clarithromycin.

Second-line H. pylori eradication therapy: H+/K+ ATPase inhibitors (omeprazole, lansoptrazole), tetracycline, bitsmuth, metronidazole.

Other inhibitors of gastric secretion: H2-receptors antagonists drugs (cimitidine, ranitidine, famotidine), M-cholin-receptor antagonists drugs.

Antacids.

Table 3. Treatment of Peptic Ulcers
Treatment	Comment	Options
radication of Helicobacter pylori	Treatment duration is 10 to 14 days (although courses lasting 1 to 7 days have been reported to have comparable effectiveness Eradication rates 80 to 90 % or higher	Omeprazole 20 mg 2t daily or lansoprazole 30 mg 2td plus amoxicillin 1 g 2td or metronidazole 500 mg 2td (if allergic to penicillin) plus clarithromycin 500 mg 2td
		Ranitidine bismuth citrate (Tritec)* 400 mg 2td plus clarithromycin 500 mg 2td or metronidazole 500 mg 2td plus tetracycline 500 mg 2td or amoxicillin 1 g 2td
		Levofloxacin 500 mg daily plus amoxicillin 1 g two times daily plus pantoprazole 40 mg two times daily
		Bismuth subsalicylate 525 mg (2 tablets) 4 times daily plus metronidazole 250 mg 4t daily plus tetracycline 500 mg 4t daily plus H2 blocker for 28 days or proton pump inhibitor for 14 days
Histamine H2 blockers	70 to 80 % healing in duodenal ulcer after 4 weeks, 87 to 94 % after 8 weeks	Ranitidine 150 mg 2t daily or 300 mg at night Famotidine 20 mg 2t daily or 40 mg at night Cimetidine 400 mg 2t daily or 800 mg at night
Proton pump inhibitors	Treatment duration is 4 weeks for duodenal ulcer and 8 weeks for gastric ulcer 80 to 100 % healing	Omeprazole 20 mg daily Lansoprazole 15 mg daily Rabeprazole 20 mg daily Pantoprazole 40 mg daily
Sucralfate (Carafate)	Treatment duration is 4 weeks Effectiveness similar to H2 blockers	1 g 4 times daily
Surgery	Rarely needed	Duodenal ulcer: truncal vagotomy, selective vagotomy, highly selective vagotomy, partial gastrectomy Gastric ulcer: partial gastrectomy with gastroduodenal or gastrojejunal anastomosis

Complications of gastric resection Early satiety and vomiting. Rapid gastric emptying leads to distension of the proximal small intestine as the hypertonic contents draw fluid into the lumen. This leads to abdominal discomfort and diarrhoea after eating. Autonomic reflexes release a range of gastrointestinal hormones which lead to vasomotor features such as flushing, palpitations, sweating, tachycardia and hypotension ('early dumping'). Patients should therefore avoid large meals with high carbohydrate content.

Late dumping syndrome. Symptoms of dumping occur 90-180 minutes after eating. The pathogenesis is broadly similar to early dumping, but in addition reactive hypoglycaemia occurs and may cause mental confusion. Rapid emptying of carbohydrates into the proximal small intestine results in an exaggerated release of insulin with subsequent reactive hypoglycaemia.

Secondary prevention of PU – by H+/K+ ATPase inhibitors.