Gastroenterology; Upper GI; Peptic Ulcer Disease Flashcards
Define peptic ulcer disease [1]
Peptic ulcer disease may be defined as ulceration in the stomach or duodenum
NB: many patients are managed with the clinical diagnosis of ‘dyspepsia’ as opposed to the endoscopic diagnosis of peptic ulcer disease.}
PUD is highly correllated to which organism? [1]
H. pylori
Describe the clinical features of peptic ulcer disease [3]
- Epigastric pain that radiates to the back
- N & V
- Dyspepsia
Describe pathophysiology of PUD [2]
The mucosa lining inner lining of the stomach and duodenum secretes bicarbonate into this mucus coating to neutralise stomach acid & digestive enzymes
Disruption of the mucus barrier or increase stomach acid increase the risk of mucosal ulceration.
Risk factors for PUD? [6]
Helicobacter pylori is associated with the majority of peptic ulcers:
- 95% of duodenal ulcers
- 75% of gastric ulcers
Drugs:
- NSAIDs
- SSRIs
- corticosteroids
- bisphosphonates
Zollinger-Ellison syndrome
State for duodenal or gastric ulcers the following:
- % related to H.pylori
- Weight loss is more likely
- If malignant
Duodenal:
- 95/99% related to H.pylori
- Not malignant (most cases)
- Weight loss less likely
Gastric:
- Weight loss likely (pain on eating)
- 60/70% related to H.pylori
- NSAIDs significant cuase
- 5-10% malignant
What investigations would you conduct for H. pylori ? [3]
Helicobacter pylori should be tested by:
- either a Urea breath test (goes red)
- stool antigen test should be used first-line
- endoscopy: rapid urease test (CLO test) can be performed to check for H. pylori. A biopsy is considered during endoscopy to exclude malignancy.
How can you distinguish between duodenal and gastric ulcers based off symptoms? [4]
Eating typically worsens the pain of gastric ulcers.
The pain of duodenal ulcers tends to improve immediately after eating, followed by pain 2-3 hours later
Patients with gastric ulcers tend to lose weight due to the fear of pain on eating.
Duodenal ulcers, the weight is stable or increases
Describe management of PUD [4]
PPI:
- lansoprazole
- omeprazole
Treat H.pylori using triple therapy (x2 antibiotics; x1 PPI)
Stop NSAIDs
Confirm eradicaiton using endoscopy and / or faecal antigen or urea breath test
Why do NSAIDs increase chance of gastric related ulcers? [1]
Inhibition of COX-1 in the gastrointestinal tract leads to a reduction of prostaglandin secretion and its cytoprotective effects in gastric mucosa
Describe the different pathways for duodenal and gastric ulcer pathways
Duodenal ulcer pathway;
antral gastritis, increased acid secretion which causes gastric metaplasia in the duodenal and leads to a duodenal ulcer
Gastric ulcer pathway:
corpus gastritis – inflammation in the body of the stomach, decreased acid secretion which causes gastric atrophy and predisposes you to dysplasia/neoplasia.
Why do you always biopsy a gastric ulcer? [1]
Confirm if is due to malignancy or not
Describe the managment for patients who have recurrent peptic ulcers [3]
Reducing the NSAID dose & substituting the NSAID with paracetamol
If symptoms recur after initial treatment: offer a PPI at the lowest dose possible to control symptoms:
* esomeprazole
* lansoprazole
* omeprazole
Offer H2 antagonist therapy if there is an inadequate response to a PPI:
- famotidine
- nizatidine
BMJ Best Practise
When should barium radiography be used for investigating POD? [1]
Barium radiography should be reserved for patients who are unable or unwilling to undergo endoscopy, and it is not routinely recommended.
Describe complications of significant peptic ulcerations [4]
Haematemesis (vomiting blood)
Coffee ground vomiting
Melaena (black, tarry stools)
Fall in haemoglobin on a full blood count
Why could an acute ulcer perforation cause abdominal ‘board like rigidity?’
Causes generalised peritonitis: presents with characteristic “boardlike” rigidity of the abdominal wall
Where is the most common place for duodenal ulceration?
Duodenal ulcers occur most frequently in the first portion of the duodenum (over 95%), with approximately 90% located within 3 cm of the pylorus and are usually less than or equal to 1 cm in diameter
In a patient with upper abdominal symptoms, what would indicate a perforated peptic ulcer on AXR? [1]
Free air on an erect chest X-ray
Classic example of gross pneumoperitoneum from a perforated gastric ulcer presenting as subdiaphragmatic free gas on chest x-ray. The patient report recent NSAID and heavy alcohol use.
What is the classical presentation of perforated stomach ulcer (classic triad and others?) [6]
The classical triad:
- abdominal pain
- tachycardia
- abdominal rigidity.
Additional:
- Peritonitis
- Abdominal distention & tenderness
- Fever
- Nausea and vomiting
- Dyspepsia
- Constipation
- Anaemia
In practice, most patients present with symptoms of an acute abdomen.
Investigations for perforated peptic ulcer? [5]
Bloods:
- Leukocytes present
- Anaemia
U & E:
- Significant bleeding may alter electrolytes
- Urea may be raised: digested blood is protein source
Liver function: useful to rule out biliary pathology
XR:
- upright XR if acute upper abdominal pain
- See free air presence
CT scan: if not seen on XR, but clinical presentation suggests
Describe the treatment pathway for the initial resuscitation of perforated peptic ulcer disease [4]
IV fluids
Nasogastric tube insertion:
- reduces amount of gastric fluids in GIT AND allows nill by mouth
IV PPI
- loading and maintence doses
- enhance sealing of perforation
Antibiotics:
- stop sepsis due to leaking of fluids into peritoneum
After initial resuscitation, describe the operative management for PPUs [3]
Operative:
- Closure of perforation < 2 cm ulcer
- Resection of lesion > 2cm ulcer
- Use piece of omentum to cover}
Describe the post-op management of PPUs [2]
Upper endoscopy:
- ID cause of perforation & healing of ulcer
- Biopsy for H. pylori
H.pylori eradication:
- triiple therapy for 10-14 days
Describe what is meant by Zollinger-Ellison syndrome [1]
It is made from a triad of which three causes? [3]
Zollinger-Ellison syndrome (ZES) is a condition caused by a gastrin-secreting tumour that causes hypersecretion of gastric acid leading to ulcer disease.
Triad:
1) gastric acid hypersecretion, sustained by:
2) fasting serum hypergastrinemia causing:
3) peptic ulcer disease and diarrhea
