Peptic Ulcer

Question 1

Peptic Ulcer Epidemiology

Answer 1

On endoscopy for dyspepsia

• 40% have functional /non-ulcer dyspepsia
• 40% have GORD
• 13% have ulcer disease
• 2% have gastric cancer
• 1% have oesophageal cancer

Question 2

Peptic Ulcer Aetiology

Answer 2

• H. pylori
• NSAIDs
• Smoking
• Alcohol
• Bile acids
• Steroids
• Stress

Question 3

Peptic Ulcer Presentation

Answer 3

• Symptoms vary, diagnosis is unreliable on history alone
• Epigastric pain 1-3 hours post-prandial
• Straight after meal in gastric, 2-3 hours after in duodenal
• Nausea
• Oral flatulence
• Sometimes heart-burn (more associated with GORD)
• Posterior ulcer may cause pain radiating to back

Question 4

Peptic Ulcer Differentials

Answer 4

• AAA
• GORD
• Gastric cancer
• Gallstones
• Chronic pancreatitis
• Crohn’s disease
• Diverticular disease
• IBS
• Drug-induced dyspepsia
• Zollinger-Ellison

Question 5

Peptic Ulcer Ix

Answer 5

• Iron deficiency anaemia on FBC
• Carbon-13 urea breath test or stool antigen test
• Endoscopy not required unless patient is presenting for the first time above the age of 55 or there are warning signs
• Iron-deficiency anaemia, chronic blood loss, WL, progressive dysphagia, persistent vomiting, epigastric mass
• If over 55 also refer if
• Previous gastric ulcer, previous gastric surgery, pernicious anaemia, NSAID use, FHx CA

Question 6

Peptic Ulcer Management

Answer 6

• Stop causative drugs

- Cessation of smoking

Question 7

Peptic Ulcer H. pylori Negative Management

Answer 7

• Stop NSAIDs
• PPI
• If high CV risk continue aspirin
• NSAID negative H.pylori negative is rare
• Herbals and OTC may be cause
• Zollinger-Ellison

Question 8

Peptic Ulcer H. pylori Positive Management

Answer 8

• Present in almost all cases of duodenal ulcer and most cases of gastric
• Higher risk of developing adenocarcinoma
• Can cause MALT lymphoma which is usually cured by eradication
• Triple therapy
• PPI and 2 antibxs
• Amoxicillin + either clarithromycin or metronidazole
• If penicillin allergic, clarithromycin and metronidazole
• Second line is amoxicillin + whichever of C/M was not used
• Only check for eradication if symptoms return

Question 9

Peptic Ulcer Complications

Answer 9

• Haematemesis or melaena
• Perforation leading to acute abdomen with epigastric pain
• Scarring of duodenum may lead to pyloric stenosis with vomiting and WL (rare)