Gastro - Online MedEd - peptic ulcer

Question 1

PUD - what is it?

Answer 1

Ulcers of stomach and duodenum

• Gastric ulcers - H. pylori (usually)
• Duodenum - H. pylori (always)

Question 2

5 aetiologies of PUD

Answer 2

1. H. pylori
2. NSAIDs
3. Malignancy
4. Curling ulcers
5. Cushing ulcers
6. Gastrinoma (ZE syndrome)

Question 3

Presentation of PUD

Answer 3

1. Asymptomatic (20%)
2. Gnawing epigastric pain - someway related to food
   - Worse with eat = gastric ulcer
   - Better with eat, pain hours later = duodenal ulcer (acid leave stomach to duodenum)
   - History is insufficient to determine location of ulcer

Question 4

Diagnosis of PUD

Answer 4

Endoscopy and biopsy
-Rule out malignancy
-Rule out H. pylori
-Look at ulcer and kind of know what type:
NSAIDs - shallow and multiple
Malignancy - big, heaped up margins, necrotic centre
-H. pylori - single ulcer

Question 5

Curling ulcer

Answer 5

Think of curling iron –> occur in burn patients

Question 6

Cushing ulcer

Answer 6

Occur with increased intracranial pressure, also on steroids and ventilators
-With these people, want to feed as early as possible (NG tube trickle feed) and use GUT prophylaxis/PPI = develop ulcers in hospital

Question 7

Gastrinoma

Answer 7

Refractory ulcer, usually multiple

Question 8

Treat all ulcers what to do?

Answer 8

Stop smoking and drinking - impair healing
Stop NSAIDs - actually a cause of ulcers
PPI - ulcers better and symptomatic better
-Sometimes need to restart NSAID/i.e. aspirin –> so start with high dose PPI to treat ulcer, then continue on low dose PPI as prophylaxis
-PPI better than H2 blockers

Question 9

What are the complications of PUD?

Answer 9

Perforation
Bleeding
Gastric outlet obstruction

Question 10

EGD and biopsy main purpose is

Answer 10

Dx and rule out cancer

Question 11

H. pylori treatment

Answer 11

Triple therapy

• Clarithromycin
• Amoxicillin/Metronidazole if penicillin allergic
• PPI

Question 12

Malignancy ulcer disease treat

Answer 12

Stage and treat

Question 13

H. pylori - what is it?

Answer 13

Infectious organism AND carcinogen
Most of the world is infected 50% exposed
85% asymptomatic
Small number will present with dyspepsia, PUD, small number with cancer/maltoma
*So need to treat H. pylori because can develop into cancer

Question 14

Diagnosis of H. pylori

When to do each test and when useful

Answer 14

Each test has a particular use:

1. Serology - test and treat method, if positive serology, then treat (but could be previous infection), in order to treat, patient should not have been treated in past + have symptoms (after treatment, serology not useful)
2. Urea breath - initial diagnosis
3. Stool Ag - for after treatment/eradication
4. EGD Bx - the best; 1. Rapid urease test/change colour, 2. Culture, long time to come back, 3. Histology, see organism under microscopy **Best is histology

Question 15

Zollinger Ellison - pathology

Answer 15

Gastrinoma
Cells at tend of stomach release gastrin –> stimulate parietal cells to make acid in stomach
-Gastrinoma - gastrin producing tumour (i.e. in pancreas) - makes gastrin regardless of how much acid in stomach (exogenous source of gastrin)
-Lots of acid = lots of ulcers
-Decrease in gastric pH (inappropriate)

Question 16

Zollinger ellison ulcers

Answer 16

Big, virulent, refractory ulcers

Question 17

ZE syndrome - history

Answer 17

Might have diarrhea, PUD symptoms

Prior PPI, not better

Question 18

ZE syndrome - persistent symptoms - how to diagnose?

Answer 18

Gastrin level - really high: >1600 is gastrinoma
If gastrin level is moderate –> do secretin stimulation test (gastrin levels increase)
Next have to find gastrinoma –> use the somatostatin receptor syntography - look for gastrinoma wherever or CT scan

Question 19

Treatment of ZE syndrome

Answer 19

Resection

If not, ZE tumour is benign –> but continuous secretion of gastrin –> cause gastric cancer