10/5- Peptic Ulcer Disease and Helicobacter Pylori Flashcards
What is dyspepsia?
Epigastric pain or discomfort
- Recurrent
- Relief obtained by eating or taking antacids
What is the DDx for dyspepsia?
- Peptic disease
- Gastroesophageal reflux disease (GERD)
- Unknown (Non-ulcer dyspepsia)
What is peptic ulcer disease?
- Symptoms
- Prognosis
- Abdominal pain
- Reduced quality of life
- Risk of complications (~25%)
- Costs (drugs, doctor visits, tests, lost time from work, etc)
- Increased mortality compared to those without ulcer disease
What characterizes:
- Erosion
- Ulcer
- Penetrating ulcer
- Erosion: into mucosa
- Ulcer: into muscularis mucosa
What is seen here?
Chronic gastric ulcer
Describe ulcer pain
- Location
- Timing
- Epigastric
- Relates to acid cycle
- Episodic, recurrent
Describe the pain and acid cycle
- Low acid in the morning
- Acid rises after meal, and brings pain
- About 1 hr after meals, pt will feel pain
What is the most common cause of upper GI bleeding?
Peptic ulcer
What are the main locations of peptic ulcers?
- Pyloric valve (near duodenum)
- Stomach (typically along minor curvature)
What is seen here?
Peptic ulcer near pyloric valve?
What is seen here?
Peptic ulcer on minor curvature of stomach?
What is seen here?
From left to right:
- Active gastric ulcer
- Healing
- Healed
What is the treatment for ulcers?
Heal the ulcer, relive pain
- Antisecretory therapy (proton pump inhibitor or H2-receptor antagonist)
Eliminate the cause
- Cure H. pylori infection
- Stop NSAIDs (e.g., ibuprofen)
- Control tumor-produced excess acid secretion (Zollinger-Ellison Syndrome)
What are common causes of ulcers?
- H. pylori infection
- Drug use (esp NSAIDs)
- Pathologic hypersecretory states (Zollinger-Ellison syndrome)
- Rare causes (Herpes simplex, tumors, Crohn’s disease…)
What is H. pylori infection?
- When acquired
- Prognosis
- Transmissible infectious disease
- Acquired in childhood
- Disease manifestations usually in adults with variable latent periods
- High morbidity, Modest mortality
- Curable
What is this?
Describe the causative agent.
H. Pylori infection
- Gm
- spiral bacteria
- Niche: human stomach
Causes inflammation:
- Atrophic gastritis
- Peptic ulcer
- Gastric cancer
Outcomes of H. pylori infection?
Atrophic gastritis
- > Gastric cancer
- > Gastric ulcer
Acute gastritis
Acute on chronic gastritis
- > Antral Predominant gastritis
- > duodenal ulcer
- > Lymphoma
What are causative associations of H. pylori?
Progressive gastro-duodenal damage
- Disordered regulation of acid secretion
Diseases: gastric adenocarcinoma, peptic ulcer (gastric and duodenal), gastric lymphoma, atrophic gastritis, gastric atrophy, vitamin B12 malabsorption (pernicious anemia), iron deficiency anemia, idiopathic thrombocytopenia (ITP), dyspepsia, etc.
Risk factors for Hp infection
- Low socio-economic status
- Birth in a developing country
- Crowded living conditions
- Sharing a bed as a child
- Absence of hot water tap in home
- Poor sanitary conditions
How is H pylori transmitted?
“Situational Opportunistic transmission”; any method of gaining access to the stomach will do
- Gastro-oral (e.g. vomit)
- Fecal-oral
- Contaminated water or food
Who should be tested for Hp?
- Dyspepsia
- Ulcer disease
- Present/past history
- 1st degree relatives
- Gastric cancer
- Family history of gastric cancer
- After endoscopic resection of gastric cancer
- If you plan to start therapy with: chronic NSAIDs or chronic PPI therapy (for GERD)
- Evaluate Hp eradication
- Pt desires to be tested
What are tests for finding/treating H. pylori?
- Serologic (ELISA): lab based or office urine (IgG antibody tests)
- Endoscopic
- Breath tests: measure change in concentration of urea (urease converts urea -> CO2 + NH3)
- Stool antigen tests
How good is serology for the diagnosis of H pylori?
- Specificity and Sensitivity good but not excellent
- Antibodies can remain for years after elimination of the infection
- Can not be used to confirm eradication
- Not generally recommended unless high pretest probability (eg, DU)
What diagnostic methadologies are preferred for diagnosing Hp?
Non invasive:
- Breath tests
- Stool antigen tests
What is seen here?
See hyperplasia of folia (?)
- Chemical cause (think NSAIDs)
What is seen here?
H. pylori infection
What is seen here?
H. pylori infection
When should endoscopy be done for Dx of Hp?
- Geographic (Korean, Japanese)
- Alarm features present: weight loss/mass, bleeding, advanced age, long history, significant anorexia, UGI bleeding/anemia, significant vomiting, x-ray suggests ‘cancer’
NOT:
- Classic Hx GERD
- Lack of alarm features
So if pt presents with dyspepsia, what are treatment options for their answer to “are serious signs/symptoms present” or “does pt have long hx GERD”?
Yes symptoms/GERD:
- Endoscope to rule out gastric CA or Barrett’s
No symptoms/GERD:
- Non-invasive Hp testing
- If test +, give multidrug Hp and confirm cure after 4 wks
- If test -, give anti-secretory drug to treat symptoms
What are the rules of thumb for Hp therapy?
- 2+ antibiotics; any PPI + any 2 (best with all 4):
- Clarithromycin
- Amoxicillin
- Metronidazole
- Acid suppression
- Duration: 14 days
- Confirm cure (UBT or stool antigen test)
3 areas of choices for Hp eradication?
- Treat with antibiotics
- Vaccine: therapeutic or preventative
- Improve the environment (good housing, sanitation, food, clean water, no crowding…)
What are characteristics of complicated PUD?
- Bleeding
- Perforation
- Obstruction
- Penetration
__% of people with peptic ulcers develop a potentially life-threatening complication
What is the most common complication?
25% of people with peptic ulcers develop a potentially life-threatening complication
- Bleeding is most common (and more frequent with NSAID users)
What are signs/symptoms of free perforation?
- Acute onset of severe pain
- Board like rigidity of abdomen
- Absent bowel sounds
- Free air in abdomen
Call surgeon!
What is seen here?
Contained perforation/perforation
What surgery can be done for PUD?
Attacked acid secretion physiologically
- Cephalic phase -> cut vagus
- Gastric phase -> remove antrum (gastrin)
- Remove acid cells -> gastrectomy
What is a Billroth I procedure?
Removal of stomach antrum and sewn directly onto duodenum
What is a Billroth II?
What is Zollinger Ellison Syndrome?
Gastrin-producing tumor
- Non-beta cell tumor of the pancreas that produces gastrin (malignant >benign).
- Gastrin secretion is not responsive to the normal down-regulatory events and thus causes sustained high levels of acid secretion
- Gastric acid hypersecretion
- Ulcers in unusual locations
- Diarrhea
- Parathyroid adenomas
What are clues to Zollinger-Ellison syndrome?
- Non-H. pylori, non-NSAID duodenal ulcer disease
- Ulcers beyond the duodenal bulb (post-bulbar ulcers)
- High rates of secretion of concentrated (>100 mmol/L) acid
- High serum gastrin levels
What is therapy for Zollinger-Ellison syndrome?
- Search for the tumor (often in duodenal wall). Remove if possible (benign)
- Control acid secretion with sufficient doses of proton pump inhibitor medications orally
What are the main conditions associated with elevated gastring composition?
How are they distinct?
Atrophic gastritis or PPI therapy
- No acid
- High gastrin (normal regulation)
ZE syndrome
- High acid
- High gastrin (abnormal regulation; b/c of ectopic production of gastrin)
Describe the circuit of acid secretion/inhibition in the stomach?
Cells:
- G cell- secrete gastrin
- D cell- secrete somatostatin (inhibits gastrin)
- Parietal cells- secrete acid
Process:
- Food and high pH stimulate antral gastrin release which travels via the blood to the produce acid by the parietal cells
- High acid then interacts with the antral D cells which make somatostatin and turn down gastrin and thus acid secretion
Summary: Peptic Ulcer Disease in the 21st century
- The focus is on prevention, cure and treatment based on etiology.
- The most common causes are infection with H. pylori and use of NSAIDs
- NSAID use has rapidly become the most common cause of ulcer disease and ulcer complications
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