GI Ulcers

Question 1

Define GI ulcer.

Answer 1

Erosion of the mucosa of the stomach (gastric ulcer) or the proximal duodenum (duodenal ulcer)
More than 5mm in diameter with depth.

Question 2

How can you differentiate between the pain of a gastric and duodenal ulcer?

Answer 2

Gastric - made worse be eating - increase acid production in response to food
Duodenal - relieved by eating, worse 2 hours after meals - neutralize acid in response to food (bile secretion)

Question 3

What are the red flags for a GI ulcer?

Answer 3

New onset dysphagia
Aged >55yrs with weight loss and either upper abdo pain, reflux or dyspepsia
New onset dyspepsia not responding to PPI treatment

Question 4

What are the risk factors for a GI ulcer?

Answer 4

Disrupt mucus barrier - H.pylori
NSAIDs/Steroids

Increase stomach acid - stress, alcohol, caffeine, smoking, spicy foods

Question 5

What are the different treatment options for GI ulcers?

Answer 5

Is clinical features and no red flags: treat empirically
Often triple therapy: PPI with oral amoxicillin + clarithromycin or metronidazole for 14 days

Question 6

What investigations should be done for suspected GI ulcers?

Answer 6

Non-invasive H.pylori testing - carbone-13 urea breath test or a stool antigen test, if positive treat empirically
Endoscopy - gold standard for diagnosis, used in patient with red flags or not responding to triple therapy.

Question 7

What is the basic pathophysiology of peptic ulcers?

Answer 7

Mucosa lines the inner stomach and duo
Secretes mucus containing bicarbonate (neutralise stomach acid), protects from acid and digestive enzymes
Dispurting the mucus barrier ot increasing stomach acid increase risk of ulceration

Question 8

What increase the risk of bleeding from a peptic ulcer?

Answer 8

NSAIDs
Aspirin
Anti-coagulants (DOACs)
Steroids
SSRI anti-depressants

Question 9

What type of peptic ulcer is more common?

Answer 9

Duodenal ulcer

Question 10

How do peptic ulcers prsent?

Answer 10

Epigastric discomfort or pain (typically worse at night)
Nausea and vomiting
Dyspepsia
Heart burn
Loss of appetite
Upper abdominal tenderness on examination

Question 11

What are the signs of upper gastrointestinal bleeding?

Answer 11

Haematemesis (vomiting blood)
Coffe ground vomiting
Malaena (black, tarry stool)
Fall in Haemoglobin on a full blood count.
Chronic microscopic bleeding can lead to iron deficient anaemia, low Hb, low MCV and low ferritin.

Question 12

What is the long term management of peptid ulcers?

Answer 12

Maintain lifestyle changes
Repeat endoscopy (6 weeks) to ensure the uulcer heals ad if appropriate repeat test for H.pylori
Try to avoid NSAID use, recommend paracetamol over ibuprofen, if NSAID is required reduce dosage and time span and give with a PPI.

Question 13

What are the potential complication of a peptic ulcer?

Answer 13

Bleeding from ulcer
Perforation - acute abdominal pain and peritonitis - requires urgent laparoscopic surgical repair.
Gastric outlet obstruction - due to scaring and strictures narrowing outlet, present with upper abdominal discomfort, abdominal distention and vomiting, particularly after eating - treated with a balloon dilation during an endoscopy or surgery.
Complication of H.pylori infection - increase risk of gastric cancer.

Question 14

What does H.pylori look like on a gram stain?

Answer 14

Gram negative spiral shaped bacterium

Question 15

What x-ray would be requested for a suspected peptic ulcer?
What would be seen on a positive scan?

Answer 15

Erect XR
Air under diaphgram- Riglers sign (air both sides of bowel wall) - indicates perforation
Bullseye sign - barium meal collected in ulcer

Question 16

What lifestyle changes should you encourage for a patient with a peptic ulcer?

Answer 16

Lose weight if they are overweight or obese
Avoid trigger foods aka chocolate, spicy foods
Eat smaller meals, and ear evening meals 3-4 hrs before going to bed if possible
Stop smoking
Reduce alcohol consumption to recommended limits if appropriate.
Assess for stress, anxiety and depression is appropraite

Question 17

What conditions must be met when testing for H.pylori infection in suspected peptic ulcers?

Answer 17

For both carbon 13-urea breath test or stool antigen test - must not have taken a PPI in the past 2 weeks or antibiotics in the past 4 weeks.

Question 18

How does the treatment for peptic ulcers vary is the proven gastric ulcer is associated with NSAIDs and positive for H.pylori?

Answer 18

Prescible full dose PPI therapy for 2 months, then prescribe first line eradication therapy after completion

Question 19

What is the treatment for peptic ulcers that are H.pylori positive and not associated with NSAID use?

Answer 19

Prescibe first line eradication therapt

Question 20

What is the treatment for peptic ulcers not associated with H.pylori infection?

Answer 20

Prescribe full dose PPI therapy for 4-8 weeks depending on clinical judgement.

Question 21

What are the different eradication regimes for peptic ulcers associated with H.pylori infection?

Answer 21

1. 7 days of 2x daailt PPI, daily amoxicillin and either twice daily clarithromycin or metronidazole
2. If allergic to penicillin all PPI, clarithromycin and metronidazole BD
3. If previous exposure to clarithromycin and allergic to penicillin - PPI BD, metrondazole BD, tetracycline hydrochloride QDS and bismuth subsalicylate QDS.

Question 22

What is the epidemiology of peptic ulcers?

Answer 22

5-10% lifetime prevalance
Gastric peaks in 5th to 7th decade
Duodenal peaks in 3rd to 5th decade.
More common in men

Question 23

What are some common differentials for peptic ulcer disease?

Answer 23

Oesophageal cancer
Stomach cancer
Gastro-oesophageal reflux disease (GORD)

Question 24

What are the potential complications of treatment with PPIs?

Answer 24

gastritis
C.diff infection

Question 25

What is the rapid urease test?

Answer 25

H.pylori urease enzyme converts urea and water to ammonia and carbon dioxide.

Question 26

What is the C-13 urea breath test?

Answer 26

H.pylori urease enzyme converts urea and water to ammonia and carbon dioxide.
No antibiotics for 4w, no antacids immediately before, no PPIs/H2 receptor antagonists for 2 weeks before - ensure high acid content and optimal H.pylori populations.
Take baseline CO2 sample, drink citric acid and solution and C-13 urea, wait 30 minutes, recollect CO2 sample, test for level of raised Carbon isotopes by mass spectrometer.