[11] Peptic Ulcer Disease Flashcards
What is the main symptom of peptic ulcer disease?
Epigastric pain
What are the features of the pain in duodenal ulcers?
Occurs before meals and at night
Relieved by eating
What are the features of the pain from gastric ulcers?
Worse on eating
Relieved by antacids
What are the risk factors for peptic ulcer disease?
H. Pylori NSAIDs Steroids Smoking Alcohol Stress
What is a Cushing’s ulcer associated with?
Head injury
What is a Curling’s ulcer associated with?
Burns
How do peptic ulcers appear?
Usually punched out ulcers
What are peptic ulcers usually on a background of?
Chronic inflammation
How common are gastric ulcers compared to duodenal ulcers?
Duodenal ulcers are 4x more common
Where do duodenal ulcers occur?
Duodenal cap (1st part of duodenum)
Where do gastric ulcers most commonly occur?
Lesser curvature of gastric antrum
What are the potential complications of gastric ulcers?
Haemorrhage
Perforation
Gastric outflow obstruction
Malignancy
How can haemorrhage caused by PUD present?
Haematemesis or melaena
What can haemorrhage caused by PUD lead to?
Iron deficiency anaemia
What can perforation of PUD lead to?
Peritonitis
What are the symptoms of gastric outflow obstruction?
Vomiting
Colic
Distention
Why is PUD a risk factor for malignancy?
Because of the association of both with H. Pylori infection
Does malignant transformation occur in PUD?
Probably not
How is PUD investigated?
Bloods
C13 breath test
OGD
Gastrin levels
What needs to be checked in bloods in PUD?
FBC
Urea
What needs to be done before an OGD is performed in PUD?
Stop PPIs >2 weeks before
What can be done on OGD in PUD?
CLO/urease test for H. pylori
Biopsy of all ulcers to check for malignancy
When are gastrin levels done in PUD?
If Zollinger-Ellison syndrome is suspected
What is involved in the conservative management of PUD?
Loose weight Stop smoking Reduce alcohol Avoid hot drinks and spicy foot Stop drugs such as NSAIDs and steroids OTC antacids
What is involved in the medical management of PUD?
OTC antacids
H. Pylori eradication
Acid suppression
Give 2 examples of OTC antacids
Gaviscon
Mg trisilicate
How might H. Pylori eradication be done?
PAC 500/PMC 250
Give two examples of acid suppressants that may be used in the medical management of PUD?
PPIs, e.g. Lansoprazole
H2RAs, e.g. Ranitidine
What is an important concept in surgery for PUD?
If there is no acid, there is no ulcer
What is acid secretion in the stomach stimulated by?
Gastrin from antral G cells
Vagus nerve
What are the surgical options for PUD?
Vagotomy
Antrectomy with vagotomy
Subtotal gastrectomy
What are the types of vagotomy in PUD?
Truncal
Selective
How does a truncal vagotomy work in PUD?
Reduces acid secretion directly and through decreased gastrin
What is the problem with a truncal vagotomy?
Prevents pyloric sphincter relaxation
What is the result of a truncal vagotomy preventing pyloric sphincter relaxation?
It must be combined with pyloroplasty or gastroenterostomy
What is a pyloroplasty?
Widening of the pylorus
What happens in a selective vagotomy?
The vagus nerve is only denervated where it supplies the lower oesophageal sphincter and stomach, but the nerves of Laterjet are left intact
What do the nerves of Laterjet supply?
Pylorus
What happens in an antrectomy with vagotomy?
The distal half of the stomach is removed, and an anastomosis is made
What are the potential approaches to anastomosis in antrectomy?
Billroth 1
Billroth 2
What happens in a billroth 1 anastomosis for antrectomy?
The stomach is anastomosed directly into the duodenum
What happens in a billroth 2 anastomosis for antrectomy?
The stomach is anastomosed to a small bowel loop, with the duodenal stump oversewn
When might a subtotal gastrectomy be performed for PUD?
Occasionally performed for Zollinger-Ellison
What are the physical complications of surgery for PUD?
Increased risk of gastric cancer Reflux or bilous vomiting Abdominal fullness Stricture Stump leakage
What happens to the complication of reflux or bilious vomiting over time?
It improves
What are the metabolic complications of surgery for PUD?
Dumping syndrome
Blind loop syndrome
Vitamin deficiency
Weight loss
What are the symptoms of dumping syndrome?
Abdomen distention
Flushing
Nausea and vomiting
Fainting and sweating
What are the early effects of dumping syndrome?
Osmotic hypovolaemia
What are the late effects of dumping syndrome?
Reactive hypoglycaemia
What are the symptoms of blind loop syndrome?
Malabsorption
Diarrhoea
What happens in blind loop syndrome?
There is overgrowth of bacteria in the duodenal stump
Why can surgery for PUD cause vitamin deficiency?
Decreased action of parietal cells causes B12 deficiency
Bypassing proximal SB causes iron and folate deficiency
What can vitamin deficiency caused by surgery for PUD lead to?
Osteoporosis
Why can surgery for PUD lead to weight loss?
Malabsorption and decreased calorie intake
