6. Peptic ulcer disease Flashcards
what is the etiology of PUD?
h pylori
NSAIDs - gastric more
SSRI
zollinger ellison syndrome - gastrin secreting tumors in the pancreas or duodenum
associated with MEN1
what are the protective factors released by the stomach mucosa ?
mucus and bicarbonate secretion
what are the destructive factors of the gastric mucosa which are released?
acid
pepsin
when do PUD develop
when the destructive factors outweigh the protective factors
does alcohol use increase PUD ?
no
what are the symptoms of GASTRIC ULCER ?
epigastric pain occurs right after meals , and eating exacerbates the pain , and there is relief during fasting
antacids
bleeding gastric ulcer - melena / presyncope
vomiting
dyspepsia - indigestion - bloating , burping , upper abdominal pain , nausea
fatty food intolerance
Heart burn acid reflux
what are the symptoms of DUODENAL ULCERS ?
the pain occurs hours after meals and recourse 2-4hrs later during the night
relived with antacids and food
Dyspepsia
what sign is characteristic of gastric ulcer complicated by pancreatitis ?
posterior penetrating pain
if there is gastric outlet obstruction from healed ulcers what signs can be seen ?
abdominal distension and succession splash on stethoscope (shaking the individual by the hips to hear the gastric contents moving)
what are the signs indicative for gastric perforation ?
abdominal guarding - peritonitis
how can we diagnose PUD
upper GI endoscopy - with Hpylori testing
- endoscopy
- biopsy =- for malignancy aswell
- culturing
double contrast barium study
non invasive tests pylori test
serological testing
stool antigen
urea breath testing
where are benign gastric ulcers usually found?
antrum and lesser cuvuture
are benign gastric ulcers projectile?
no
malignant gastric ulcers are projected where?
into the lumen of stomach
complications of PUD
GI haemorrhage mortality rate of 10 percent patients over 60 highly susceptible - anemia - melena
perforation - erodes ito adjacent organs such as pancreases - pancreatitis
left hepatic lobe
- guarding abdomen
penetration
- pain radiating to the back
gastric outlet obstruction - prepyloric area
edema and scarring
- persistent vomiting
pyloric stenosis how do we temporarily fix the pyloric stenosis ?
endoscopic balloon dllation and then surgical
what are the SYMPTOMS indicative for pyloric stenosis ?
PERSISTANT vomitting , early satiety , weight loss
what are the treatment options of PUD?
kill the h pylori
with classic triple drug therapy PPI (omeprazole) + CLARITHROMYCIN + AMOXICILLIN
= for 7-14 days
then endoscopic surgery
acid suppresion
with PPI
H2 antagonist - cimetidine , ranitidine
antacids - calcium carbonate
mucosal protectants - bismuth
what s the treatment to ulcer which bleeds ?
endoscopic hemostasis - thermooagulation
hemoclips
injection of epinephrine alcohol
all of these together shows the highest effectiveness
it becomes an ulcer when the penetration goes past what ?
the lamina propria
what are the DD for PUD ?
functional dyspepsia
cholangitis
what are the endoscopic appearance of benign PUD ?
smooth ulcer base - often filled with whitish fibrinoid exudate
a punched out circumscribed margins
surrounding mucosa with radiating folds (malignancy have irregular folds)
less than 2.5cm
how many biopsies are required for the diagnosis of cancer ulcer ?
7 biopsies for 99 percent sensitivity
in the biopsy what are the tell tale signs for a chronic ulcer ?
slough and inflammatory debris containing dead cells and immune cells
granulation tissue - fibrinoid necrosis
mononuclear cells infiltration / lymph , plasma cells
what is the bleeding rate required for identification of bleeding source ?
0.5 ml /min
when there is massive GI bleeding what is needed to be performed ?
IV fluid replacement
IV vasoactive medications
IV PPI
nasogastric suction
angiography
INAPPROPRIATE FOR ENDOSCOPY
what classification is used to predict the chance of bleeding of peptic ulcer ?
forrest classification
what is the forrest classification ?
TYPE 1 active bleeding :
a) spurting - 90 percent chance
b) oozing - 80 percent chance
TYPE 2
SIGNS OF recent bleeding
a) non bleeding visible vessel - 50 percent
b) clot on lesion = 30 percent
c) haematin covered lesion = 5 percent
TYPE 3
clean base
what is the treatment when there is failure to endoscopically achieve hemostaisi or when there is perforation
oversewing
vagotomy with pyloroplasty
billroth 1 or 2 surgery
how do PPI work?
they block the proton pump which is the H+K+-atpase
how can we differentiate between benign and malignant ulcers ?
in gross appearance -cancer ulcer protruding into the lumen larger in appearance , dirty moss it has a rolled out margin irregular edges swollen and stiff surrounding mucosa
all types of ulcers are tested for ?
h pylori
