Peptic ulcer

Question 1

What is a peptic ulcer?

Answer 1

Distinct breach in the mucosal lining of either the stomach (gastric ulcer) or duodenum (duodenal ulcer)

Question 2

What are the 3 types of ulcers?

Answer 2

1. Gastric ulcers - mainly on lesser curvature
2. Duodenal ulcers - mainly on duodenal cap
3. Functional/Non-Ulcer Dyspepsia (Indigestion)

Question 3

What is the epidemiology?

Answer 3

Incidence increases with age:

• Duodenal ulcers peak in 40’s to 50’s
• Gastric ulcers peak in 50’s and 60’s

M + F equally affected

Question 4

What is the pathophysiology?

Answer 4

Imbalance between factors that damage the mucosal lining + defence mechanisms that usually limit injury

1. H.pylori
2. NSAID’s

Question 5

How does H.pylori cause ulcers?

Answer 5

In DU, H. pylori infection leads to impaired secretion of somatostatin and consequently increased gastrin release, resulting in gastric acid hypersecretion.

In GU, H.pylori infection (plus severe inflammation) leads to gastric mucin degradation, tight junction disruption and the induction of gastric epithelial cell death

Question 6

How do NSAID’s cause ulcers?

Answer 6

Trap H+ ions

Inhibit COX’s&raquo_space;> inhibit prostaglandin synthesis&raquo_space;> decreased production of protective mucus

Increased bleeding risk through anti-platelet actions

Question 7

What is the prognosis of peptic ulcers?

Answer 7

Good: DU heal in 4 wks + GU in 8 wks with PPI therapy

If due to H.pylori - 20% recurrence

If due to NSAIDs - discontinue then will have low recurrence. Continue then will have high recurrence

Question 8

What are the risk factors associated with peptic ulcers?

Answer 8

• Infection of H. pylori.
• NSAID use.
• Smoking.
• Increasing age.
• FH of peptic ulcer disease.

Question 9

What are the signs and symptoms of peptic ulcers?

Answer 9

• Abdominal pain .
• Epigastric tenderness.
• N&V
• Anaemia
• Early satiety

Question 10

What are the red flags associated with peptic ulcers?

Answer 10

Dyspepsia, 55+, anaemia, weight loss

Question 11

What are the 1st line investigations for peptic ulcers?

Answer 11

Breath test for H. pylori or a stool antigen test:

• Positive result if H. pylori present.
• Ordered in patients <55 years without alarm features.
• PPI’s, bismuth and abx can interfere with the test - stop 2 wks prior

OGD:
- Most specific and sensitive.
Initially ordered if any alarm symptoms are present, if patient is >60 years (>55 with weight loss), or if patient doesn’t respond to treatment.

Question 12

Apart from 1st line investigations, what other investigations should be conidered?

Answer 12

FBC:

• Microcytic anaemia.
• Ordered only if patients seems clinically anaemic or has evidence of GI bleeding.

Fasting serum gastrin level:
- Ordered if there are multiple duodenal ulcers or in pts with ulcers and diarrhoea

Question 13

What are the differential diagnoses?

Answer 13

• Oesophageal cancer.
• Stomach cancer.
• GORD.
• Gastroparesis.
• Biliary colic.
• Acute pancreatitis.
• Coeliac disease.
• IBS.
• Pleuritic pain.
• Pericarditis.

Question 14

What is the treatment for acute peptic ulcers?

Answer 14

Active bleeding ulcer:

• 1st line - Endoscopy +/- blood transfusion.
• Plus - PPI.
• 2nd line - Surgery.

No active bleeding and H. pylori negative:

• 1st line - Treat underlying cause plus PPI.
• 2nd line - H2 antagonist or sucralfate or misoprostol.

No active bleeding and H. pylori positive:

• 1st line - H. pylori eradiation therapy.
• 2nd line - Alternative regimen.
• 3rd line - Acid suppression therapy.

Question 15

What is the ongoing treatment for peptic ulcers?

Answer 15

Frequent recurrences, large or refractory ulcers:

- 1st line - Acid suppression therapy.

Question 16

What complications can occur with peptic ulcers?

Answer 16

• Gastric outlet obstruction.
• Upper GI bleeding&raquo_space;> haemorrhage
• Perforation - DUs perforate > GUs
• Malignancy