Gastric antral ulcer

Question 1

A 72 year old woman presents to the Emergency Department with a four day history of epigastric pain. Gastroscopy reveals evidence of a gastric antral ulcer. Can you outline your management plan?

Answer 1

Impression
My impression of this stem is that this patient has a gastric antral ulcer secondary to peptic ulcer disease.

There are a number of potential causes of PUD which would need to be considered in this patient. These include;

• Infective: H Pylori infection
• medications: NSAIDs
• neoplasia: gastric malignancy (important to rule out given age)

There are several risk factors for PUD to consider that should be elicited on thorough Hx/Ex/Ix.

Goals

• take thorough Hx/Ex/Ix, determine likely cause of ulcer
• in this case, either ceasing NSAID medication, mitigating other risk factors like alcohol use and steroid medication
• Screen for and prevent complications (bleeding, perforation)
• if H.Pylori, start with triple therapy and then assess for clearance before further treatment options to be considered.

Question 2

Gastric antral ulcer - History

Answer 2

History

• sx: pain (worse/better with eating, the SOCRATES), bowel changes, urinary changes, infective sx, weight loss/night sweats/fevers, dyspepsia (pain on eating),
• RISKS: alcohol, NSAIDS, known H.Pylori infection, steroid medications, age, smoking, stress, ZE syndrome, SSRIs
• PMHx, Meds, Allergies, PSHx, SNAP

Question 3

Gastric antral ulcer - Examination

Answer 3

Examination

• General appearance + vitals
• Abdo exam: epigastric pain/tenderness
• systems review: malignancy, troisier’s sign (palpable L supraclavicular lymph node)

Question 4

Gastric antral ulcer - Investigations

Answer 4

Investigations
Key/diagnostic
- upper endoscopy (diagnostic and therapeutic if complications) +/- biopsy if ?malignancy, can also perform biopsy urease testing
- H.Pylori breath test/stool antigen testing

Bedside: urea breath test, medications review,
Bloods: LFT, FBC +/- iron studies (if blood loss), UEC, CRP/ESR,
Imaging: AXR is perf suspected, staging imaging if malignancy

Question 5

Gastric antral ulcer - Management

Answer 5

Management
Depends on underlying aetiology

H.Pylori

• Triple therapy (esomeprazole, clarithromycin, amoxicillin for 7 days)
• Quad therapy - (antacid, PPI, metronidazole, doxycycline)
• repeat testing for resolution (2 wks post PPI, 4 wks post ABx)

NSAIDS
- cease NSAIDs and treat with PPI for 8-12 weeks

For complications

• surgical coiling/clipping to prevent bleeding
• emergent laparotomy for ?perforation
• broad spectrum ABx

Supportive

• analgesia
• diet modification (minimise spicy food ingestion,
• risk modification