19. Peptic ulcers and upper GI bleed

Question 1

what is chyme

Question 2

What is the role of mucous cells

Question 3

What is the function of chief cells

Answer 3

Chief cells secrete pepsinogen (inactive form) and in order for hydrolysis to occur you need HCL to turn it into pepsin for hydrolysis (breaks down proteins)

Question 4

what is the function of parietal cells

Question 5

what does a peptic ulcer involve

Answer 5

ulceration of the mucosa of the stomach (peptic ulcer) or the duodenum (duodenal ulcer)

Question 6

which peptic ulcer is more common

Answer 6

duodenal ulcer

Question 7

stomach mucosa is prone to ulceration from

Answer 7

breakdown of the protective layer of the stomach and duodenum & increase in stomach acid

Question 8

What is the protective layer of the stomach compromised of and what can it be broken down by

Answer 8

mucus and bicarbonate secreted by the stomach mucosa broken down by: medications (steroids and NSAIDS) and H.pylori

Question 9

what can cause an increase in acid

Answer 9

• Stress• Alcohol• Caffeine• Smoking• Spicy foods

Question 10

how does someone with peptic ulcers present

Answer 10

• Epigastric discomfort or pain• Nausea and vomiting• Dyspepsia• Bleeding causing haematemesis, “coffee ground” vomiting and melaena• Iron deficiency anaemia (due to constant bleeding)

Question 11

Eating typically worsens the pain in which condition- gastric ulcers - duodenal ulcers

Answer 11

gastric ulcers

Question 12

eating improves the pain in which condition - gastric ulcers- duodenal ulcers

Answer 12

duodenal ulcers

Question 13

How are peptic ulcers managed

Answer 13

diagnosed by endoscopy (do the rapid urease test to check for H.Pylori) treatment is the same as with GORD, usually with high dose PPI

Question 14

what are the complications of peptic ulcers

Answer 14

bleeding from the ulcer perforation resulting in an ‘acute abdomen’ and ‘peritonitis’ Scaring and strictures of the muscle and mucosa can lead to narrowing of the pylorus

Question 15

Upper GI tract bleed can be from which structures

Answer 15

oesophagusstomach duodenum

Question 16

what are the pain causes of upper GI bleeds

Answer 16

oesophageal varices mallory-weirs tear, which is a tear of the oesophageal mucous membrane Ulcers of the stomach of duodenum Cancer of the stomach or duodenum

Question 17

what is a mallory-weiss tear

Answer 17

tear of the oesophageal mucous membrane

Question 18

How does someone with an upper GI bleed present

Answer 18

• Haematemesis (vomiting blood)• “Coffee ground” vomit. This is caused by vomiting digested blood that looks like coffee grounds.• Melaena, which is tar like, black, greasy and offensive stools caused by digested blood• Haemodynamic instability occurs in large blood loss, causing a low blood pressure, tachycardia and other signs of shock. Bear in mind that young, fit patients may compensate well until they have lost a lot of blood.

Question 19

What other main symptoms will a patient have if they have a peptic ulcer

Answer 19

epigastric pain and dyspepsia

Question 20

What is the scoring system that is used in suspected upper GI bleed on their initial presentation

Answer 20

Glasgow-Blatchford Score

Question 21

What kind of things does the glasgow-blatchford score take into account

Answer 21

drop in Hbrise in ureablood pressure HRmelaena syncope

Question 22

Why does urea rise in upper GI bleeds

Answer 22

blood in the GI tract gets broken down by the acid and digestive enzymes one of the breakdown products is urea and then this urea is absorbed in the intestines

Question 23

What score is used for patients that have had an endoscopy to calculate their risk of rebreeding and mortality

Answer 23

Rockall Score

Question 24

What risk factors does the Rockall score take into account

Answer 24

• Age• Features of shock (e.g. tachycardia or hypotension)• Co-morbidities • Cause of bleeding (e.g. Mallory-Weiss tear or malignancy)• Endoscopic stigmata of recent haemorrhage such as clots or visible bleeding vessels

Question 25

What is the management of an upper GI bleed (ABATED)

Answer 25

• A – ABCDE approach to immediate resuscitation• B – Bloods• A – Access (ideally 2 large bore cannula)• T – Transfuse• E – Endoscopy (arrange urgent endoscopy within 24 hours)• D – Drugs (stop anticoagulants and NSAIDs)

Question 26

What drugs should you stop if someone is having an upper GI bleed

Answer 26

anticoags and NSAIDs

Question 27

What is group and save

Answer 27

the lab simply check the patients blood group and keeps a sample of their blood saved in case they need to match blood to it

Question 28

what is crossmatch

Answer 28

the lab actually finds blood, tests that it is compatible and keeps it ready in the fridge to be used if necessary.

Question 29

In what circumstances are platelets indicated

Answer 29

in active bleeding and thrombocytopenia (platelets less than 50)

Question 30

What is given to patients taking warfarin that are actively bleeding

Answer 30

prothrombin complex concentrate

Question 31

Patients with a history of chronic liver disease are more susceptible to what kind of bleeding

Answer 31

oesophageal varices

Question 32

What medications are used to treat someone with oesophageal varies

Answer 32

Terlipressin Prophylactic broad spectrum antibiotic

Question 33

What are differentials of severe burning in epigastrium, for a 1 week peroid

Answer 33

Gastritis- inflammation of the gastric mucosa

Non-ulcer dyspepsia- indigestion ad epigastric pain but normal gastric mucosa on endoscopy. Not possible to differentiate this from gastritis based on symptoms and the diagnosis is made after endoscopy

Then consider other causes of epigastric pain which has been present for 1 week eg pancreatitis and cholecystitis

Question 34

what are common causes of peptic ulcers

Answer 34

infection with H. pylori and use of NSAIDs

Question 35

where does H. pylori most commonly like to burrow

Answer 35

with a preference to the antrum ie the distal part of the stomach adjacent to the pyloric sphincter

Question 36

H. Pylori has a destructive impact on D cells, why is this a problem

Answer 36

which dampen down acid production in the stomach, therefore having an overall impact of increasing acid production and lowering the Ph of stomach juices

Question 37

What are other risk factors for developing peptic ulcers apart from H.pylori infection and use of NSAIDs

Answer 37

Smoking

Drinking alcohol above recommended intake

Family history of peptic ulcer disease

Physical stress – e.g. major trauma or surgery or ICU admission (often referred to as a ‘stress ulcer’

Hypersecretory syndromes which increase production of stomach acid. These are rare but you may have heard of the Zollinger-Ellison syndrome.

Question 38

Name the 3 main complications of peptic ulcers

Answer 38

bleeding

perforation

gastric outlet obstruction

Question 39

Bleeding peptic ulcer may cause IDA, what are the symptoms for this

Question 40

bleeding peptic ulcer can cause what symptoms

Answer 40

anemia symptoms (fatigue, SOB, palpitations)

haematemesis and malaena

haemorrhagic shock if big enough

Question 41

what is the issue with perforated and what does it casue

Answer 41

This is where the ulcer completely erodes through the lining of the the stomach or more commonly duodenum and stomach fluid and air escape into the peritoneal cavity

This causes an acute abdomen and peritonitis and emergency surgery is required

Question 42

Gastric outlet obstruction (GOO) is a clincial syndorme characterised by what? and casued by what?

Answer 42

epigastric abdo pain and postprandial vomitting due to mechanical obstruction

Question 43

What is the most common malignancy that would cause gastric outlet obstruction

Answer 43

The most common malignancy is pancreatic carcinoma which extends. Into the duodenum and gastric outlet followed by primary gastric cancer

Question 44

What are the risk factors for developing gastric cancer

Answer 44

chronic gastritis and usually an association with H.Pylori infection