Gastric ulceration and H. Pylori

Question 1

What are risk factors for the development of gastric ulcers?

Answer 1

• H. Pylori
• NSAID use
• Smoking
• Reflux of duodenal contents
• Delayed gastric emptying
• Stress

Question 2

What is the difference between an ulcer and an erosion?

Answer 2

A break in the mucosal lining of the stomach or duodenum more than 5 mm in diameter, with depth to the submucosa. Ulcers smaller than this or without obvious depth are called erosions.

Question 3

How do peptic ulcers occur?

Answer 3

Result from an imbalance between factors promoting mucosal damage (gastric acid, pepsin, Helicobacter pylori infection, non-steroidal anti-inflammatory drug use) and those mechanisms promoting gastroduodenal defense (prostaglandins, mucus, bicarbonate, mucosal blood flow).

Question 4

What type of bacteria is H. Pylori?

Answer 4

Slow-growing spiral gram-negative bacteria

Question 5

Where is h. pylori most commonly found?

Answer 5

Gastric antrum

Question 6

How is H. Pylori protected from gastric acid?

Answer 6

By juxtamucosal mucous layer which traps bicarbonate secreted by antral cells, and ammonia produced by bacterial urease.

Question 7

What enzyme does H. pylori possess which enables it to convert area to ammonium and chloride?

Answer 7

Urease

Question 8

What results from infection with H. Pylori?

Answer 8

• Antral gastritis
• Peptic ulceration (duodenal and gastric)
• Gastric cancer

Question 9

What are features of gastric ulcers?

Answer 9

Can be asymptomatic, but can have:

• Recurrent, burning epigastric pain - relieved by antacids
• Nausea
• Weight loss
• Symptoms of anaemia

Question 10

What are features of duodenal ulcers?

Answer 10

Can be asymptomatic, or:

• Burning epigastric pain - relieved by antacids
• Weight loss
• Signs of anaemia
• Epigastric tenderness

Question 11

What are risk factors for the development of duodenal ulcers?

Answer 11

• H. pylori
• Drugs - NSAID’s, Steroids, SSRI’s
• Increased gastric acid secretion
• Increased gastric emptying
• Smoking

Question 12

Why does chronic antral gastritis cause increased gastric acid secretion?

Answer 12

Causes hypergastrinaemia due to gastrin release from antral G cells

Question 13

What might back pain in someone with dyspeptic symtpoms, weight loss and anaemia suggest?

Answer 13

Penetration of a posterior ulcer

Question 14

What investigations would you consider going in someone with suspected peptic ulcers?

Answer 14

• Blood tests - FBC, H. pylori serology, fasting gastrin levels
• Urea breath test
• H. Pylori stool antigen test
• Upper GI endoscopy

Question 15

What is involved in the urea breath test for investigating H. Pylori?

Answer 15

Give the patient ^{<span>13</span>}C or ¹⁴C labelled urea -> Measurement of ¹³CO2 in the breath after ingestion (requires mass spectrometer). The test is sensitive (90%) and specific (96%)

Question 16

What is important to tell people to do before performing Urea breath test?

Answer 16

• Stop antibiotics for 4 weeks prior
• Stop PPIs 2 weeks prior

Question 17

What staining is used on biopsy samples for investigating for H. pylori?

Answer 17

Giemsa staining

Question 18

How would you manage someone with confirmed H. Pylori?

Answer 18

Eradication Therapy - Triple therapy for 7 days

• Clarithromycin 500mg bd
• Amoxycillin 1g bd (or Metronidazole 400mg bd)
  
  • Tetracycline is given if penicillin allergy
• PPI: e.g. omeprazole 20mg bd

Question 19

If someone was found to be negative for H. pylori as the cause of their peptic ulcer, how would you manage them?

Answer 19

Acid suppression alone

Question 20

What would be your differential diagnosis for someone with features of peptic ulceration?

Answer 20

• Non-ulcer-dyspepsia
• Duodenal crohn’s
• TB
• Lymphoma
• Pancreatic cancer

Question 21

What is important to exclude on endoscopy in someone with suspected peptic ulcer disease in older patients?

Answer 21

Gastric cancer

Question 22

What are alarm symptoms of someone with gastritis?

Answer 22

• Anaemia
• Loss of weight
• Anorexia
• Recent onset
• Malaena/haematemesis
• Swallowing difficulty

Question 23

What are complications of peptic ulceration?

Answer 23

• Haemorrhage
• Perforation
• Gastric outlet obstruction/Pyloric stenosis

Question 24

What are features of gastric outlet obstruction?

Answer 24

• Vomiting - infrequent, projectile, large in volume, contains particles of previous meals.
• Succussion splash

Question 25

When is surgery considered as an option in peptic ulceration?

Answer 25

• Recurrent uncontrolled haemorrhage
• Perforation

Question 26

What neoplastic disorders can occur due to H. Pylori infection?

Answer 26

• Gastric adenocarcinoma
• Gastric B cell lymphoma (MALT)

Question 27

What might you consider giving someone with NSAID associated ulcers which were refractory to PPI administration?

Answer 27

Misoprostol

Question 28

What tests could you perform on histological samples taken from the stomach to look for H. Pylori?

Answer 28

• Rapid urease test
• Histology
• Culture

Question 29

What is Zollinger-Ellison syndrome?

Answer 29

Syndrome caused by gastrin-secreting tumour or hyperplasia of the islet cells in the pancreas causes overproduction of gastric acid, resulting in recurrent peptic ulcers.