Lecture PUD Flashcards
What is the definition of Peptic Ulcer Disease (PUD)?
A break or defect in the gastric or small intestinal mucosa that penetrates the muscularis mucosae.
What is the typical size range for peptic ulcers?
From 5 mm to several cm.
How are erosions different from peptic ulcers?
Erosions are smaller and superficial mucosal lesions.
What is the most common infectious cause of peptic ulcers?
Helicobacter pylori infection
What is a common class of medications that can cause peptic ulcers?
NSAIDs and aspirin use
What types of tumors can lead to peptic ulcers?
Adenocarcinoma, lymphoma, metastatic lesions, and myeloproliferative disorders (polycythemia vera).
What acid hypersecretory disorder can cause peptic ulcers?
Zollinger-Ellison syndrome (gastrin-secreting tumor causing excess acid secretion).
What endocrine disorder can be associated with peptic ulcers?
Hyperparathyroidism
What inflammatory bowel disease can contribute to peptic ulcers?
Crohn’s disease
What are two granulomatous diseases that can cause peptic ulcers?
Tuberculosis and sarcoidosis
What systemic disease involving mast cells can lead to peptic ulcers?
Systemic mastocytosis
What rare infections can cause peptic ulcers, especially in immunosuppressed patients?
CMV, herpes simplex 1, EBV.
What types of vasculitis can contribute to peptic ulcers?
Behcet disease, Henoch-Schonlein purpura, polyarteritis nodosa, systemic lupus erythematosus.
How can ischemia lead to peptic ulcers?
Reduced blood flow to the stomach or duodenum can damage the mucosa.
What types of critical illness can lead to stress ulcers?
Head injury, severe burns, physical trauma, or multiple organ failure.
What chronic conditions can increase the risk of peptic ulcers?
Chronic pulmonary disease, cystic fibrosis, cirrhosis, renal failure.
Cigarette smoking promotes the development of ulcers, impairs ulcer healing, and increases recurrence. True or False?
True
Genetic factors are important in predisposing to H. pylori infection or PUD without H. pylori infection. True or False?
ture
Emotional stress might predispose some individuals to ulcers. True or False?
true
Age is a risk factor for peptic ulcers, increasing the risk of occurrence and complications. True or False?
true
Sleep and sleep apnea are risk factors for peptic ulcers. True or False?
true
Alcohol is an important risk factor for peptic ulcers, but moderate consumption has been linked with improved healing. True or False?
true
Diet is the mainstay of treatment for peptic ulcers. True or False?
false
Caffeine is a risk factor for peptic ulcers. True or False?
False
What is the fundamental imbalance that leads to peptic ulcers?
An imbalance between protective and aggressive factors in the stomach.
What are the main aggressive factors that contribute to ulcer formation?
Gastric acid and pepsin.
What are the three key protective mechanisms of the gastric mucosa?
Gastric mucus and bicarbonate production
Epithelial cell mechanisms (barrier maintenance and restitution)
Local blood flow
What are the key mediators involved in mucosal defense mechanisms?
Prostaglandins and nitric oxide.
Describe the characteristics of H. pylori bacteria.
Spiral-shaped, gram-negative, urease-producing bacteria.
Where is H. pylori found in the body?
In the mucus layer and between the mucus layer and the gastric epithelium in the stomach.
What is the function of urease produced by H. pylori?
It helps to neutralize the acidic environment of the stomach, allowing the bacteria to survive.
What diseases are associated with H. pylori infection?
Chronic active gastritis, peptic ulcer disease (PUD), gastric adenocarcinoma (gastric cancer), and MALT (mucosa-associated lymphoid tissue) lymphoma.
What is the carcinogen status of H. pylori?
It is classified as a Group 1 carcinogen by the International Agency for Research on Cancer (IARC), meaning it is a definite cause of cancer in humans.
What percentage of patients with duodenal ulcers and gastric ulcers have H. pylori infection?
70-90% of patients with duodenal ulcers and 30-60% of patients with gastric ulcers.
How is H. pylori infection treated?
Eradication therapy usually involves a combination of antibiotics and acid-suppressing medications.
How do NSAIDs contribute to peptic ulcer formation?
They inhibit COX-1 and COX-2 enzymes, which decreases prostaglandin synthesis, impairing mucosal protection.
What is the role of prostaglandins in protecting the gastric mucosa?
They maintain mucosal blood flow, increase mucus and bicarbonate secretion, and promote healing.
What factors increase the risk of peptic ulcers and GI bleeding in patients taking NSAIDs?
Age over 60, history of PUD, concurrent use of corticosteroids or anticoagulants, and significant comorbid diseases.
What is the advantage and disadvantage of COX-2 inhibitors compared to traditional NSAIDs?
They have a reduced risk of GI complications but are associated with an increased risk of coronary side effects.
What are some other potential GI complications associated with NSAID use?
Dyspepsia, ulcerations and strictures of the small intestine, acute colitis, exacerbations of IBD, ulcers, strictures, or perforation of the colon.
What is Zollinger-Ellison Syndrome (ZES)?
ZES is a rare condition caused by a gastrinoma, a neuroendocrine tumor that secretes excessive amounts of gastrin.
What are the common symptoms of ZES?
Severe peptic ulcer disease, abdominal pain, and diarrhea.
Where are gastrinomas typically located?
In the pancreas or proximal small bowel.
What are the diagnostic criteria for ZES?
High fasting serum gastrin level (>1000 pg/mL) and low stomach pH (<2.0).
What test can be used to confirm the diagnosis of ZES?
Secretin test. In ZES, gastrin levels rise after secretin administration, unlike in other conditions with elevated gastrin.
What is the association between ZES and Multiple Endocrine Neoplasia type 1 (MEN 1)?
20-25% of patients with ZES have MEN 1 syndrome, which is characterized by tumors in multiple endocrine glands.
What is a Cameron ulcer, and where is it typically located?
A Cameron ulcer is a gastric ulcer found at the level of the diaphragmatic hiatus in patients with large hiatal hernias. It is usually asymptomatic but may cause occult or overt bleeding.
What is an anastomotic ulcer, and what are its potential causes?
An anastomotic ulcer occurs at the site of a surgical anastomosis (connection) after partial gastrectomy. Ischemia and chronic inflammation from biliary reflux are potential causes.
What is a Dieulafoy ulcer, and what is its key characteristic?
A Dieulafoy ulcer is a rare but potentially life-threatening lesion characterized by a single bleeding focus with minimal mucosal disruption. It typically involves a large artery that erodes into the stomach or duodenum.
What are the typical laboratory findings in an uncomplicated peptic ulcer?
Normal complete blood count (CBC).
What type of anemia can be associated with peptic ulcer disease?
Iron deficiency anemia, which may be indicated by low hemoglobin and hematocrit levels on a CBC.
What laboratory finding may be present in a patient with an acute perforation of a peptic ulcer?
Leukocytosis, an elevated white blood cell count, indicating an inflammatory response.
What is the gold standard for diagnosing peptic ulcers?
Endoscopy.
Why is it important to obtain biopsy specimens during endoscopy for peptic ulcers?
To rule out malignancy, especially in gastric ulcers.
What can be done during endoscopy to manage actively bleeding ulcers?
Hemostasis therapy can be applied to stop the bleeding.
Differential diagnosis
GERD
Functional dyspepsia
Neoplasia (anorexia, significant weight loss, upper endoscopy with biopsy)
Biliary tract disease (abdominal ultrasound)
Hepatitis
Pancreatitis
Appendicitis
Mesenteric ischemia (elderly patients, severe atherosclerosis or risk factors, upper abdominal pain,
accentuated by a meal, patients decrease food intake, weight loss, CT angiography)
Myocardial ischemic pain (electrocardiogram, cardiac enzymes)
Pneumonia
What should be done for all patients diagnosed with peptic ulcers regarding H. pylori?
All ulcer patients should be tested and treated for H. pylori infection.
What should be done regarding NSAID use in patients with peptic ulcers?
NSAIDs should be discontinued to promote ulcer healing and prevent recurrence.
What is the initial treatment for patients with upper GI bleeding who are suspected of having an ulcer?
**They should be started on intravenous proton pump inhibitors (PPIs) **to reduce acid secretion and promote hemostasis.
How do PPIs work to block acid secretion?
They irreversibly bind and inhibit the hydrogen-potassium ATPase pump on the luminal surface of the parietal cell.
Name some common PPIs.
Omeprazole, lansoprazole, pantoprazole, rabeprazole, esomeprazole.
What is the typical dosage and duration of PPI treatment for peptic ulcers?
40 mg twice daily for 8 weeks.
What are the typical healing rates for NSAID-induced gastric ulcers and duodenal ulcers with PPI treatment?
85% for NSAID-induced gastric ulcers and 90% for duodenal ulcers.
When is the optimal time to take PPIs for peptic ulcer treatment?
30 minutes before a meal.
What are some potential side effects of PPIs?
Although rare, side effects can include Clostridium difficile infection, pneumonia, and bone fracture.
List the Histamine 2 (H2)-receptor antagonists used in peptic ulcer treatment.
Cimetidine, Ranitidine, Famotidine, Nizatidine.
How do H2-receptor antagonists compare to PPIs in terms of effectiveness?
They are inferior to PPIs but superior to placebo. They are useful in patients who cannot tolerate PPIs.
How does Sucralfate work in treating peptic ulcers?
It is a sucrose salt that binds to tissue proteins and forms a protective barrier, decreasing exposure of the epithelium to acid, bile salts, and pepsin.
How does Misoprostol work in treating peptic ulcers?
It is a prostaglandin E1 analog that inhibits gastric acid secretion, stimulates bicarbonate and mucus secretion, and enhances mucosal blood flow.
What is the most common complication of peptic ulcers, and what percentage of ulcers bleed?
GI bleeding, occurring in 15% of peptic ulcers.
How does GI bleeding from peptic ulcers typically present?
Hematemesis (vomiting blood), melena (black, tarry stools), or hematochezia (bright red blood in stool).
What is the incidence of perforation in peptic ulcers, and how does it present?
Perforation occurs in 7% of cases and presents with severe abdominal pain and a rigid abdomen due to peritonitis.
What is meant by penetration as a complication of peptic ulcers?
It refers to the ulcer extending into adjacent organs, such as the pancreas or liver, leading to pancreatitis or hepatitis.
What is the incidence of obstruction in peptic ulcers, and what causes it?
Obstruction occurs in 2% of cases and is caused by inflammation and edema in the prepyloric area, leading to narrowing of the gastric outlet.
Common sources of UGB
Peptic ulcer disease 50%
Duodenal ulcer
Gastric erosions
Gastric ulcer
Esophagogastric varices
Mallory Weiss tear
Esophagitis
Erosive Duodenitis
Most common place for UGB?
Proximal to the ligament of treitz
