6. Peptic ulcer disease

Question 1

what is the etiology of PUD?

Answer 1

h pylori

NSAIDs - gastric more

SSRI

zollinger ellison syndrome - gastrin secreting tumors in the pancreas or duodenum
associated with MEN1

Question 2

what are the protective factors released by the stomach mucosa ?

Answer 2

mucus and bicarbonate secretion

Question 3

what are the destructive factors of the gastric mucosa which are released?

Answer 3

acid

pepsin

Question 4

when do PUD develop

Answer 4

when the destructive factors outweigh the protective factors

Question 5

does alcohol use increase PUD ?

Answer 5

no

Question 6

what are the symptoms of GASTRIC ULCER ?

Answer 6

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

Question 7

what are the symptoms of DUODENAL ULCERS ?

Answer 7

the pain occurs hours after meals and recourse 2-4hrs later during the night

relived with antacids and food

Dyspepsia

Question 8

what sign is characteristic of gastric ulcer complicated by pancreatitis ?

Answer 8

posterior penetrating pain

Question 9

if there is gastric outlet obstruction from healed ulcers what signs can be seen ?

Answer 9

abdominal distension and succession splash on stethoscope (shaking the individual by the hips to hear the gastric contents moving)

Question 10

what are the signs indicative for gastric perforation ?

Answer 10

abdominal guarding - peritonitis

Question 11

how can we diagnose PUD

Answer 11

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

Question 12

where are benign gastric ulcers usually found?

Answer 12

antrum and lesser cuvuture

Question 13

are benign gastric ulcers projectile?

Answer 13

no

Question 14

malignant gastric ulcers are projected where?

Answer 14

into the lumen of stomach

Question 15

complications of PUD

Answer 15

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

Question 16

pyloric stenosis how do we temporarily fix the pyloric stenosis ?

Answer 16

endoscopic balloon dllation and then surgical

Question 17

what are the SYMPTOMS indicative for pyloric stenosis ?

Answer 17

PERSISTANT vomitting , early satiety , weight loss

Question 18

what are the treatment options of PUD?

Answer 18

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

Question 19

what s the treatment to ulcer which bleeds ?

Answer 19

endoscopic hemostasis - thermooagulation
hemoclips
injection of epinephrine alcohol

all of these together shows the highest effectiveness

Question 20

it becomes an ulcer when the penetration goes past what ?

Answer 20

the lamina propria

Question 21

what are the DD for PUD ?

Answer 21

functional dyspepsia

cholangitis

Question 22

what are the endoscopic appearance of benign PUD ?

Answer 22

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

Question 23

how many biopsies are required for the diagnosis of cancer ulcer ?

Answer 23

7 biopsies for 99 percent sensitivity

Question 24

in the biopsy what are the tell tale signs for a chronic ulcer ?

Answer 24

slough and inflammatory debris containing dead cells and immune cells

granulation tissue - fibrinoid necrosis

mononuclear cells infiltration / lymph , plasma cells

Question 25

what is the bleeding rate required for identification of bleeding source ?

Answer 25

0.5 ml /min

Question 26

when there is massive GI bleeding what is needed to be performed ?

Answer 26

IV fluid replacement

IV vasoactive medications

IV PPI

nasogastric suction

angiography

INAPPROPRIATE FOR ENDOSCOPY

Question 27

what classification is used to predict the chance of bleeding of peptic ulcer ?

Answer 27

forrest classification

Question 28

what is the forrest classification ?

Answer 28

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

Question 29

what is the treatment when there is failure to endoscopically achieve hemostaisi or when there is perforation

Answer 29

oversewing

vagotomy with pyloroplasty

billroth 1 or 2 surgery

Question 30

how do PPI work?

Answer 30

they block the proton pump which is the H+K+-atpase

Question 31

how can we differentiate between benign and malignant ulcers ?

Answer 31

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

Question 32

all types of ulcers are tested for ?

Answer 32

h pylori