19. Peptic ulcers and upper GI bleed Flashcards
what is chyme
What is the role of mucous cells
What is the function of chief cells
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)
what is the function of parietal cells
what does a peptic ulcer involve
ulceration of the mucosa of the stomach (peptic ulcer) or the duodenum (duodenal ulcer)
which peptic ulcer is more common
duodenal ulcer
stomach mucosa is prone to ulceration from
breakdown of the protective layer of the stomach and duodenum & increase in stomach acid
What is the protective layer of the stomach compromised of and what can it be broken down by
mucus and bicarbonate secreted by the stomach mucosa broken down by: medications (steroids and NSAIDS) and H.pylori
what can cause an increase in acid
• Stress• Alcohol• Caffeine• Smoking• Spicy foods
how does someone with peptic ulcers present
• Epigastric discomfort or pain• Nausea and vomiting• Dyspepsia• Bleeding causing haematemesis, “coffee ground” vomiting and melaena• Iron deficiency anaemia (due to constant bleeding)
Eating typically worsens the pain in which condition- gastric ulcers - duodenal ulcers
gastric ulcers
eating improves the pain in which condition - gastric ulcers- duodenal ulcers
duodenal ulcers
How are peptic ulcers managed
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
what are the complications of peptic ulcers
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
Upper GI tract bleed can be from which structures
oesophagusstomach duodenum
what are the pain causes of upper GI bleeds
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
what is a mallory-weiss tear
tear of the oesophageal mucous membrane
How does someone with an upper GI bleed present
• 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.
What other main symptoms will a patient have if they have a peptic ulcer
epigastric pain and dyspepsia
What is the scoring system that is used in suspected upper GI bleed on their initial presentation
Glasgow-Blatchford Score
What kind of things does the glasgow-blatchford score take into account
drop in Hbrise in ureablood pressure HRmelaena syncope
Why does urea rise in upper GI bleeds
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
What score is used for patients that have had an endoscopy to calculate their risk of rebreeding and mortality
Rockall Score
What risk factors does the Rockall score take into account
• 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
What is the management of an upper GI bleed (ABATED)
• 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)
What drugs should you stop if someone is having an upper GI bleed
anticoags and NSAIDs
What is group and save
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
what is crossmatch
the lab actually finds blood, tests that it is compatible and keeps it ready in the fridge to be used if necessary.
In what circumstances are platelets indicated
in active bleeding and thrombocytopenia (platelets less than 50)
What is given to patients taking warfarin that are actively bleeding
prothrombin complex concentrate
Patients with a history of chronic liver disease are more susceptible to what kind of bleeding
oesophageal varices
What medications are used to treat someone with oesophageal varies
Terlipressin Prophylactic broad spectrum antibiotic
What are differentials of severe burning in epigastrium, for a 1 week peroid
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
what are common causes of peptic ulcers
infection with H. pylori and use of NSAIDs
where does H. pylori most commonly like to burrow
with a preference to the antrum ie the distal part of the stomach adjacent to the pyloric sphincter
H. Pylori has a destructive impact on D cells, why is this a problem
which dampen down acid production in the stomach, therefore having an overall impact of increasing acid production and lowering the Ph of stomach juices
What are other risk factors for developing peptic ulcers apart from H.pylori infection and use of NSAIDs
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.
Name the 3 main complications of peptic ulcers
bleeding
perforation
gastric outlet obstruction
Bleeding peptic ulcer may cause IDA, what are the symptoms for this
bleeding peptic ulcer can cause what symptoms
anemia symptoms (fatigue, SOB, palpitations)
haematemesis and malaena
haemorrhagic shock if big enough
what is the issue with perforated and what does it casue
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
Gastric outlet obstruction (GOO) is a clincial syndorme characterised by what? and casued by what?
epigastric abdo pain and postprandial vomitting due to mechanical obstruction
What is the most common malignancy that would cause gastric outlet obstruction
The most common malignancy is pancreatic carcinoma which extends. Into the duodenum and gastric outlet followed by primary gastric cancer
What are the risk factors for developing gastric cancer
chronic gastritis and usually an association with H.Pylori infection
