GI - Peptic Ulcer Disease

Question 1

Peptic ulcer disease: presentation

Answer 1

• Epigastric pain that can radiate to the back
• Bleeding
• Duodenal: before meals and at night, relieved by eating (food is alkaline so raises pH in duodenum)
• Gastric: worse on eating (wt loss) and relieved by antacids

Question 2

Peptic ulcer disease: risk factors

Answer 2

• H pylori
• NSAIDs, steroids
• Smoking, EtOH
• Physiological stress

Question 3

Peptic ulcer disease: pathophysiology

Answer 3

• Punched out ulcers
• usually on background of chronic inflammation
• D.U.: 4x more common than GU, usually in 1st part of duodenum
• G.U.: lesser curve of gastric antrum

Question 4

Peptic ulcer disease: complications

Answer 4

• Haemorrhage: haematemesis/malena + Fe deficient anaemia
• Perforation: peritonitis
• Gastric outflow obstruction: colic, vomiting, distension
• Malignancy: actual malignant transformation probably doesn’t occur but at high risk if associated with H pylori infection

Question 5

Peptic ulcer disease: Ix

Answer 5

• Bloods: FBC (anaemia), U+E (raised urea in haemorrhage)
• Urease breath test/C13 breath test for H pylori
• OCG: biopsy all ulcers (check for malignancy)
• Gastrin levels: Zollinger-Ellison suspected

Question 6

Peptic ulcer disease: Mx - conservative

Answer 6

• Lose wt
• stop smoking and EtOH
• Avoid hot drinks/spicy foods
• Stop drugs: NSAIDs/steroids
• OTC antacids

Question 7

Peptic ulcer disease: Mx - medical

Answer 7

• OTC antacids
• H pylori eradication with PAC 500 (PPI, amoxicillin + clarythromicin)
• Acid suppression: lansoprasole 30mg OD/BD, ranitidine 300mg (nocte)

Question 8

Perforated peptic ulcer: pathophysiology

Answer 8

• Perforated duodenal ulcer is most common (1st part duodenum - highest acid concentration). If anterior perf (air under diaphragm, if posterior can erode into gastroduodenal A, if in 3/4 part no air under diaphragm b/c that part is Retroperitoneal.
• Perforated GU
• Perforated gastric Ca

Question 9

Perforated peptic ulcer: presentation

Answer 9

• suddenly onset severe pain, beginning in epigastrium and then becoming more generalised
• vomiting
• peritonitis

Question 10

Perforated peptic ulcer: differential

Answer 10

• Pancreatitis
• Acute cholecystitis
• AAA
• MI

Question 11

Perforated peptic ulcer: Ix

Answer 11

• Bloods: FBC, U+E, amylase, CRP, G+S, clotting
• Urine dipstick
• Imaging: erect CXR
• AXR: rigler’s sign with air on both sides of bowel wall

Question 12

Perforated peptic ulcer: Mx - Resus

Answer 12

• Aggressive fluid resus: catheter + fluids
• Analegesia: morphine
• ABX: check local guidelines (Kettering = co-amoxiclav and metronidazole)
• NGT

Question 13

Perforated peptic ulcer: Mx - conservative and surgical

Answer 13

• Conservative: if pt isn’t peritonitic
• Surgical laparotomy: abdo washout/excise ulcer/repair omentum, etc.
• *Always test for H pylori b/c 90% of perforated PU are associated with H pylori

Question 14

Gastric Outlet Obstruction: cause

Answer 14

-Late complication of peptic ulcer disease leading to fibrotic structuring

Question 15

Gastric Outlet Obstruction: presentation

Answer 15

• Hx of bloating, early satiety and nausea

- Outlet obstruction: copious projectile, non bilious vomiting a few hours after meals + epigastric distension

Question 16

Gastric Outlet Obstruction: Rx

Answer 16

• Correct metabolic abnormality: 0.9% Na + KCl
• Benign: endoscopic ballon dilatation or pyloroplasty
• Malignant: stenting/resection

Question 17

Hypertrophic pyloric stenosis: Presentation and Mx

Answer 17

• Presentation: 6-8 was, projectile vomit minutes after feed, RUQ mass, visible peristalsis
• hypochloraemic, hypokalaemic metabolic alkalosis
• Mx: resus + correct metabolic abnormality, NGT and Ramstedt pyloromyotomy (divide muscularis propria)