peptic ulcer Flashcards
definition
Peptic ulcer disease (PUD) is an umbrella term for the development of two different ulcers: gastric ulcers and duodenal ulcers.
what layers of the GI tract consist of the mucosa
epithelium
lamina propria
aetiology
- NSAID
- H. pylori
- zollinger-ellison syndrome (gastrin secreting tumour)
- SSRIs
- smoking
- blood group O
location
lesser curve - gastric
posterior wall of duodenum - watch gastroduodenal artery
pathophysiology
- factors that disrupt the mucus barrier or increase stomach acid
presentation
epigastric pain
bloating
vommiting / nausea
gastric:
- pain inc when eating - subsides after 2-3hrs
- weight loss
duodenal:
- pain subsides when eating - arrives 2-3hrs after
- weight gain
appearance of ulcer
round
circular
punched out
clean base
investigations
Gastric -
1st line/Gold standard - endoscopy + biopsy
Duodenal -
1st line - (H pylori tests) urea breath test and faecal antigen test
Can’t have PPI for 2 weeks before
Can’t have Abx 4 weeks before
Endoscopy higher risk of iatrogenic damage
management
- lifestyle changes - drinking, caffine, smoking
- stop NSAIDs
- PPIs - 4 weeks
- H2 receptor antagonists if PPIs dont work
H. pylori - clarithromycin + amoxicillin
- rescope ulcer after 6-8 weeks
what to do after rescoped ulcer after 6-8 weeks
healed:
- low dose PPI
- H2 antagonist if no PPI
not healed:
- malignancy?
- different H. pylori meds
- PPI for 4 more weeks
most common cause of duodenal ulcer
H. pylori (90%)
complications of peptic ulcers
- bleeding
- perforation
- gastric outlet obstruction
- gastric adenocarcinoma
Investigations to diagnose ulcers (4)
If no red flags:
- non-invasive testing
1. Urea breath test
2. Stool antigen test
If red flags:
Urgent endoscopy + biopsy
(Will see Brunner’s gland hypertrophy- more mucous production)
Location of Duodenal ulcers? (2)
-Mostly at D1 and sometimes D2
-The gastroduodenal artery is located at the posteromedial aspect of D2 so deeply penetrating ulcers in this region can result in a torrential upper GI bleed
What type of peptic ulcer is more common?
Duodenal
What do you have to make sure of before testing for H.pylori? (2)
If testing for h.pylori, patient must be off PPI for 2 weeks+ (all ulcers)
- otherwise you can get a false -ve
Where do gastric ulcers occur
Mostly at a lesser curve
when is a repeat endoscopy needed after treatment
6-8 weeks after the start of PPI
whens full dose ppi given
H. pylori
Causes of duodenal ulcers (3)
H. Pylori (causes 95% of duodenal ulcers)
NSAIDS
ZE Syndrome
Symptoms of duodenal ulcers (4)
Epigastric pain
- worse between meals
- better with food
* typically weight gain
Investigations to diagnose duodenal ulcers (4)
If no red flags:
- non-invasive testing
1. Urea breath test
2. Stool antigen test
If red flags:
Urgent endoscopy + biopsy
(Will see Brunner’s gland hypertrophy- more mucous production)
Treatment for both gastric and duodenal peptic ulcers? (5)
STOP THE CAP
Stop NSAIDs
1) H.pylori +ve -> triple therapy
CAP
Clarythromycin
Amoxicillin
PPI (omeprazole)
(If they have a penicillin allergy replace amoxicillin with metronidazole)
2) H.Pylori -ve give PPI at initial high dose for a month until ulcer healed
Ensure all patients who have a proven ulcer have a repeat endoscopy 6-8 weeks later to confirm healing as well as h.pylori retesting
Where do gastric ulcers occur
Mostly at a lesser curve
Causes of gastric ulcers (3)
-H.pylori (causes of 75% of gastric ulcers)
-NSAIDs
-Zolinger Ellison syndrome:
- pancreatic tumour
- gastric acid hypersecretion
- recurrent peptic ulcers
Symptoms of gastric ulcers (4)
Epigastric pain
- worse on eating
- better between meals + with antacids
* typically weight loss
Investigations to diagnose gastric ulcers (4)
If no red flags (55+, haematemesis/melaena, anaemia, dysphasia)
- non invasive tests:
c-urea breath test
Stool antigen test
If red flags
- urgent endoscopy + biopsy
Complications of peptic ulcer disease (3)
-Bleeding
-Perforation: life threatening as ulcer penetrates the duodenum or stomach into the peritoneal cavity; requires surgical intervention
-Gastric outlet obstruction: caused by obstruction at pylorus due to an ulcer and subsequently scarring. Presents with vomiting and nausea after food
