Gastric/duodenal ulcer disease

Question 1

Describe a peptic ulcer

Answer 1

Peptic ulcers involve ulceration of the mucosa of the stomach (gastric ulcer) or the duodenum (duodenal ulcer). Duodenal ulcers are more common.

Question 2

Pathophysiology

Answer 2

The stomach mucosa is prone to ulceration from:

Breakdown of the protective layer of the stomach and duodenum
Increase in stomach acid
There is a protective layer in the stomach comprised of mucus and bicarbonate secreted by the stomach mucosa. This protective layer can be broken down by:

Medications (e.g. steroids or NSAIDs)
Helicobacter pylori

Question 3

What can cause increased acid?

Answer 3

Stress
Alcohol
Caffeine
Smoking
Spicy foods

Question 4

How do peptic ulcers present?

Answer 4

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

Question 5

How do gastric ulcers and duodenal ulcers differ presentation wise?

Answer 5

eating typically worsens the pain of gastric ulcers and improves the pain of duodenal ulcers.

Question 6

Management of peptic ulcers

Answer 6

Peptic ulcers are diagnosed by endoscopy. During endoscopy a rapid urease test (CLO test) can be performed to check for H. pylori. Biopsy should be considered during endoscopy to exclude malignancy as cancers can look similar to ulcers during the procedure.

Medical treatment is the same as with GORD, usually with high dose proton pump inhibitors. Endoscopy can be used to monitoring the ulcer to ensure it heals and to assess for further ulcers.

Question 7

Complications of peptic ulcers

Answer 7

Bleeding from the ulcer is a common and potentially life threatening complication.

Perforation resulting in an “acute abdomen” and peritonitis. This requires urgent surgical repair (usually laparoscopic).

Scarring and strictures of the muscle and mucosa. This can lead to a narrowing of the pylorus (the exit of the stomach) causing difficulty in emptying the stomach contents. This is known as pyloric stenosis. This presents with upper abdominal pain, distention, nausea and vomiting, particularly after eating.