Peptic ulcer

Question 1

Classification of peptic ulcers?

Answer 1

Acute: drugs (NSAIDS)

Chronic: drugs, H. pylori, ↑Ca, Zollinger-Ellison

Question 2

Gastric ulcers pain fx

Answer 2

Epigastric pain

Worse on eating

Relieved by antacids, wt loss

Question 3

Duodonal ulcer pain fx

Answer 3

Epigastric pain

Before meals and at night,

Relieved by eating or milk

Question 4

RFs of gastric ulcer

Answer 4

H. pylori (80%),

Smoking,

Drugs,

Delayed gastric emptying,

Stress (Cushing’s: intracranial disease, Curling’s: burns, sepsis, trauma)

Question 5

RFs of duodenal ulcer

Answer 5

H. pylori (90%)

Drugs: NSAIDs, steroids

Smoking

EtOH

↑ gastric emptying

Blood group O

Question 6

Complications of peptic ulcers

Answer 6

Haemorrhage

Perforation

Gastric Outflow Obstruction

Malignancy (↑ risk ̄c H. pylori)

Question 7

Haematemesis

Answer 7

vomiting of blood

Question 8

Zollinger-Ellison

Answer 8

one or more tumours form in pancreas or the upper part of small intestine (duodenum)

Increased production of gastrin

Increased stomach acid

Question 9

Conservative management of peptic ulcer disease?

Answer 9

Lose wt

stop smoking

↓ EtOH

Avoid hot drinks and spicy food

Stop drugs: NSAIDs, steroids

OTC antacids

Question 10

Medical management of peptic ulcer disease?

Answer 10

OTC antacids: Gaviscon, Mg trisilicate

H. pylori eradication: PAC500 or PMC250

1-2mo PPIs: lansoprazole

H2RAs: ranitidine

Question 11

H. pylori eradication

Answer 11

PAC 500

PPIS: lansoprazole 30 mg BD

Amoxicillin 1g BD

Clarithromycin 500mg BD

PMC 250

PPIS

Metronidazole 400mg BD

Clarithromycin 250mg BD

Question 12

Surgery for peptic ulcer disease

Answer 12

• Secretion stimulated by gastrin and vagus
  1. vagotomy
  2. anterectomy + vagotomy
  3. Subtotal gastrectomy c ̄ Roux-en-Y

Question 13

Physical complications of PUD surgery?

Answer 13

Stump leakage

Abdominal fullness

Reflux or bilious vomiting (improves ̄c time)

Stricture

Question 14

Metabolic complications of PUD surgery?

Answer 14

Dumping syndrome

Early: osmotic hypovolaemia

Late: reactive hypoglycaemia

Blind loop syndrome

Anaemia

Question 15

Dumping syndrome

Answer 15

Occurs when food, especially sugar enters small bowel too quickly

Abdo distension, flushing, n/v

Question 16

Blind loop syndrome

Answer 16

→ malabsorption, diarrhoea

Overgrowth of gut flora bacteria in duodenal stump

Question 17

Duodenal stump?

Answer 17

portion of duodenum not removed during gastric surgery

Question 18

Symptoms of perforated peptic ulcer

Answer 18

Sudden onset severe pain in epigastrium then becoming more generalised

Vomiting

Peritonitis

Question 19

CXR and AXR for perforated peptic ulcer

Answer 19

Erect CXR: Air under diaphragm in 70%

Abdo XR: Rigler’s sign (air both sides of bowel wall)

Question 20

Resus rx of perforated peptic ulcer

Answer 20

NBM/fluids, Analgaesia

Ceftriaxone and metronidazole

NG tube

Question 21

Conservative rx of perforated ulcer

Answer 21

If not peritonitic omentum may seal perforation spontaneously in 50%

Question 22

Surgical rx of perforated peptic ulcer

Answer 22

Duodenal ulcer - abdo washout + omental patch repair

Gastric ulcer - excise ulcer and repair