PUD

Thursday, May 4, 2023 2:53 PM

Epigastric pain/discomfort ddx

• GERD
• PUD
• Gastritis
• Acute Pancreatitis
• MI
• Lower lobe pneumonia
• Pancreatic pseudocyst

PEPTIC ULCER DISEASE QUES:

Your next patient at the ED is a 45 years old male complaining of colicky abdominal pain since last night
after eating fried chicken at an Indian restaurant.
TASKS 1. Further focused history 2. Physical examination findings from the examiner 3. Arrange
investigations 4. Most likely diagnosis and management

❑HISTORY:
❑Greet
❑HD stability
❑Allergy Offer painkiller
❑HPC: SOCRATES
❑ pain: When did it start? How did it start? What were you doing at that time? 1st time?
❑ Site of the Pain: Where exactly is the pain? Can you point with 1 finger where exactly is the pain?
❑ Character: What type of pain is it? Is it stabbing, cramping, crushing?
❑ Radiation: Is the pain going anywhere else?
❑ Timing: Is it a continuous or an on and off pain?
❑ Exacerbating/relieving factors: anything that makes it better or worse? Have you taken medications
for the pain?
Associated Qs: fever/ nausea/ vomiting/diarrhoea
DDx Qs:
❑GERD/PUD: any bitter taste in mouth? Any relationship with food esp. hot spicy or acidic food? Any
heart burn or something travel up towards the throat? Burning pain middle of chest?
❑Gall stone/ cholecystitis: Does the pain get worse after taking fatty food/ heavy meal?
❑Hepatitis/ Cholangitis: any yellowish discoloration of skin/eyes or urine? What is the colour of your
stool?
❑Gall stone ileus: how about your bowel habit? When was the last time u passed stool? Any tummy
distension/ swelling?
❑MI/ IHD: any chest pain/ racing of heart?
❑Lower lobe pneumonia: any fever/cough/sob?
❑Rule out malignancy: any LOA/ LOW/ lump or bump?
❑Red flag: any difficulty swallowing/ any blood in the stool or vomiting? Do u feel tired or weak?
❑Waterworks: have you noticed any changes in the color and smell of your urine? Do you experience
increased frequency, burning or stinging during your urination?
❑Bowel changes=> constipation anr diarrhoea?
SADMA questions:
❑Do you smoke? If yes, for how long and how many sticks on the average per day?
❑Do you drink alcohol? If yes, how often and what type and how much?
❑Do you use any recreational drugs?
❑Do you take any prescription or over the counter medications? (NSAID)
❑Allergies?
Past medical history: any medical conditions you have been treated for in the past and surgical illness?
Family history: any family history of gallbladder disease, peptic ulcer disease, liver disorders?

Physical examination:
❑GA PICKLED( pallor, icterus, dehydration)
❑Vitals and BMI
❑focused ABDOMEN:
▪ Inspection: Any visible distension/ mass/ scar marks?
▪ Palpation: any tenderness/ guarding/ rigidity? Any palpable mass? Murphy’s sign r/o cholecystitis? RIF
tenderness, LIF tendernes
▪ Auscultation: bowel sound present/ absent?
With the consent of my patient and presence of a chaperone I would like to do the per rectal
examination. - bld on my finger to r/o melena
❑Other systemic examination
❑Office test: UDT, BSL

❑EXPLAIN:
▪From history & examination, most probably you have ulcer in your stomach or first part of your small
gut , we call it peptic ulcer disease.
▪ Your stomach and first part of the gut is protected by a mucous layer which protects the stomach from
ulcer .
▪ But as you’re taking NSAID for a long time and also there are some bacteria called Helicobacter pylori
that can break the integrity of this layer and causes ulcer.
▪ At this point I’d like to refer you to a gastroenterologist who will do endoscopy and biopsy. They will
insert a tube with a mini camera through your mouth to the stomach to look at the lining and will take
some samples to check the presence of the bug and rule out any nasty changes. Pls don’t worry, it will
be totally painless.
▪ If H. pylori is positive, we’ll give you triple therapy that contains: ▪ - Proton Pump Inhibitor which will
reduce acid secretion
▪ - 2 antibiotics: Clarithromycin or Amoxycyllin plus Metronidazole
▪ Antibiotics are given for 1-2 weeks and proton pump inhibitor 4-8 weeks
❑Stop Neurofen and change to another painkiller (paracetamol or COX 2 inhibitor)
❑Lifestyle modification advice ▪ - Reduce your weight
▪ - Stop smoking
▪ - Reduce your alcohol intake
▪ - Maintain your diet regularly
▪ - Relaxation therapy
❑It’s a common condition, not dangerous, easily treated, usually the ulcer will heal in 1-2 weeks, and
success rate is very good – over 90%. With triple therapy, the chance of relapse is low.
❑Review after endoscopy results come back.
❑Red flags blood in vomit, bleeding through back passage, lethagy, dizziness