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Peptic ulcer disease Flashcards

1
Q

What is peptic ulcer disease?

A

Peptic ulcer disease (PUD) is a break in the inner lining of the stomach, the first part of the small intestine, or sometimes the lower esophagus

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2
Q

What are common causes of peptic ulcer disease?

A

H. pylori
NSAID use

Less common include tobacco, smoking, stress

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3
Q

Who is most sensitive to developing peptic ulcer disease after NSAID use?

A

Older people

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4
Q

What are the signs and symptoms of peptic ulcer disease?

A 
Abdominal (mainly epigastric) pain
Bloating
Nausea
Heartburn
Blood in stool
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5
Q

What is the effect of eating on the pain in peptic ulcer disease?

A

Gastric ulcer –> worse

Duodenal ulcer –> better

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6
Q

What are the risk factors for developing peptic ulcer disease?

A

Heartburn
Gastroesophageal reflux disease
NSAID use

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7
Q

What are the complications of peptic ulcer disease?

A

Gastrointestinal bleeding (can be lethal! Most common)
Perforation
Cancer (H. pylori)

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8
Q

What do parietal cells secrete?

A

HCl

Intrinsic factor

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9
Q

What do G cells release?

A

Gastrin, stimulate parietal cells

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10
Q

NSAIDs can increase the risk of peptic ulcer disease. What other medications, taken with aspirin, increase this risk?

A 
Aspirin
SSRIs
Corticosteroids
Antimineralocorticoids
Anticoagulants
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11
Q

How do NSAIDs increase the risk of peptic ulcer disease?

A

The gastric mucosa protects itself from gastric acid with a layer of mucus, the secretion of which is stimulated by certain prostaglandins.

NSAIDs block the function of cyclooxygenase 1 (COX-1), which is essential for the production of these prostaglandins.

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12
Q

How is peptic ulcer disease diagnosed?

A

Characteristic symptoms:
1. Stomach pain

Esophagogastroduodenoscopy

Potentially Barium swallowing

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13
Q

What layer do peptic ulcers affect?

A

Muscularis mucosae and lamina propria

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14
Q

how can you diagnose the presence of H. pylori?

A

Urea breath test, as H. pylori secretes urease
Culture from endoscopy
Rapid urease test

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15
Q

What is the macroscopic appearance of peptic ulcers?

A

Gastric ulcers are most often localized on the lesser curvature of the stomach.

The ulcer is a round to oval parietal defect (“hole”), 2–4 cm diameter, with a smooth base and perpendicular borders

Surrounding mucosa may present radial folds, as a consequence of the parietal scarring

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16
Q

What is the microscopic appearance of peptic ulcers?

A

Penetration of muscularis mucosae and lamina propria, usually produced by acid-pepsin aggression

During the active phase, the base of the ulcer shows 4 zones: fibrinoid necrosis, inflammatory exudate, granulation tissue and fibrous tissue

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17
Q

How can you prevent peptic ulcers?

A

PPI with NSAIDs

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18
Q

How would you manage H. pylori induced peptic ulcer disease?

A

A triple regimen in which pantoprazole and clarithromycin are combined with either amoxicillin or metronidazole. 7-14 days

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19
Q

How would you manage NSAID induced peptic ulcer disease?

A

NSAID-associated ulcers heal in 6 to 8 weeks provided the NSAIDs are withdrawn with the introduction of proton pump inhibitors

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20
Q

What is the Glasgow-Blatchford score?

A

A screening tool to assess the likelihood that a person with an acute upper gastrointestinal bleeding will need to have medical intervention such as a blood transfusion or endoscopic intervention

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21
Q

What criteria are considered in the Glasgow-Blatchford score?

A 
Blood urea
Haemoglobin
Systolic blood pressure
Pulse
Melaena (dark stool)
Syncope
Hepatic disease
Cardiac failure
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22
Q

What is the Rockall score?

A

Identifies patients at risk of adverse outcome following acute upper gastrointestinal bleeding.

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23
Q

What criteria are considered in the Rockall score?

A 
Age
Shock
Co-morbidity
Diagnosis
Evidence of bleeding
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24
Q

How do you notice upper gastrointestinal bleeding?

A

Blood in vomit
Black stool
Hypovolaemic shock

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25
What are upper gastrointestinal bleedings caused by?
Peptic ulcers Gastric erosions Esophageal varices Mallory-Weiss tear
26
What are the signs in upper gastrointestinal bleeding?
Vital signs are deteriorating quickly: a medical emergency!
27
What is the prognosis for uppper gastrointestinal bleeds?
Depending on its severity, upper gastrointestinal bleeding may carry an estimated mortality risk of 11%
28
How would you manage someone with acute gastrointestinal bleeding?
Transfuse patients with massive bleeding with blood, platelets and clotting factors Offer endoscopy to unstable patients with severe acute upper gastrointestinal bleeding immediately after resuscitation
29
How would you manage someone with acute gastrointestinal bleeding who is taking warfarin?
Offer prothrombin complex concentrate
30
How would you manage non-variceal bleeding?
After stabilisation! For the endoscopic treatment of non-variceal upper gastrointestinal bleeding, use one of the following: 1. a mechanical method (for example, clips) with or without adrenaline 2. Thermal coagulation with adrenaline 3. Fibrin or thrombin with adrenaline DO NOT offer PPI before endoscopy
31
How would you manage variceal bleeding?
Resuscitate Offer terlipressin to patients with suspected variceal bleeding at presentation Offer prophylactic antibiotic therapy at presentation to patients with suspected or confirmed variceal bleeding
32
How would you manage oesophageal varices?
Use band ligation in patients with upper gastrointestinal bleeding from oesophageal varices Consider transjugular intrahepatic portosystemic shunts (TIPS) if bleeding from oesophageal varices is not controlled by band ligation
33
How would you manage gastric varices?
Offer endoscopic injection of N-butyl-2-cyanoacrylate to patients with upper gastrointestinal bleeding from gastric varices Offer TIPS as secondline
34
How would you control bleeding and prevention of re-bleeding in patients on NSAIDs, aspirin or clopidogrel?
Continue low-dose aspirin for secondary prevention of vascular events Stop other NSAIDs during acute phase of bleeding Discuss the risks and benefits of continuing clopidogrel
35
What is a Mallory Weiss tear?
Bleeding from a laceration in the mucosa at the junction of the stomach and esophagus
36
What are Mallory Weiss tears usually caused by?
Alcoholism Bulimia Any other cause of vomiting
37
What are Mallory Weiss tears signs and symptoms?
Vomiting blood | Blood in stool
38
How would you manage a Mallory Weiss tear?
Treatment is usually supportive as persistent bleeding is uncommon Cauterisation or injection with epinephrine can be used to stop bleeding
39
How would you diagnose a Mallory Weiss tear?
Endoscopy
40
What is Boerhaave syndrome?
A full thickness oesophageal rupture due to vomiting
41
What are signs and symptoms of esophageal rupture?
History of retching and vomiting, immediately followed by excruciating retrosternal chest and upper abdominal pain
42
How would you diagnose an oesophageal rupture?
Plain chest radiography and confirmed by chest CT scan. Usually reveals mediastinal or free peritoneal air as the initial radiologic manifestation
43
How would you managee a ruptured oesophagus?
Mortality if untreated is near 100% Treatment includes immediate antibiotic therapy to prevent mediastinitis and sepsis, surgical repair of the perforation
44
Where is the tear in Boerhaave's syndrome usually located?
The left postero-lateral aspect of the distal esophagus and extends for several centimetres (lower 1/3 of oesophagus)
45
What is the difference between Boerhaave's syndrome and a Mallory-Weiss tear?
Boerhaave: full oesophageal rupture | Mallory-Weiss: mucosal tear
46
What is Barrett's oesophagus?
Barrett’s oesophagus is a precancerous condition characterised by abnormal replacement of the squamous epithelium of the lower oesophagus by a type of columnar epithelium resembling that in the stomach and intestine.
47
What microscopic change can be seen in Barret's oesophagus?
stratified squamous epithelium to simple columnar epithelium with interspersed goblet cells
48
What are risk factors of Barrett's oesophagus?
Oesophageal adenocarcinoma
49
What is the main cause of Barret's oesophagus?
Adaptation to chronic exposure from acid reflux
50
How would you diagnose Barret's oesophagus?
Endoscopy and biopsy
51
How would you microscopically stage Barret's oesophagus?
The cells of Barrett's esophagus are classified into four categories: nondysplastic, low-grade dysplasia, high-grade dysplasia, and frank carcinoma
52
How would you manage Barret's oesophagus?
In Barrett's oesophagus with no dysplasia or low‑grade dysplasia, periodic endoscopic surveillance and repeat biopsies may be considered with the aim of early detection of progression to high‑grade dysplasia or cancer. If high‑grade dysplasia or early cancer (carcinoma in situ) is detected, then surgery or ablation
53
What are the symptoms of Barret's oesophagus?
Heartburn Dysphagia Vomiting blood Pain under sternum
54
What is Gastroesophageal reflux disease (GERD)?
A chronic condition in which stomach contents rise up into the esophagus, resulting in either symptoms or complications
55
What are the signs and symptoms of gastroesophageal reflux disease (GERD)?
``` Acidic taste in the mouth Regurgitation Heartburn Pain with swallowing Chest pain ```
56
What are the complications following gastroesophageal reflux disease (GERD)?
Complications include esophagitis, esophageal stricture, and Barrett's esophagus
57
What are the risk factors for gastroesophageal reflux disease (GERD)?
Risk factors include obesity, pregnancy, smoking, hiatal hernia, and taking benzodiazepines, calcium channel blockers, tricyclic antidepressants and NSAIDs.
58
What is the problem in gastroesophageal reflux disease (GERD)?
Mechanical: poor closure of the lower oesophageal sphincter
59
How is gastroesophageal reflux disease (GERD) diagnosed?
``` Symptoms Endoscopy (and biopsy) ```
60
How is gastroesophageal reflux disease (GERD) managed?
Lifestyle: less coffee, acidic, spicy food. Weight loss Medication: PPI and antacids Surgery
61
Name a proton-pump inhibitor?
Omeprazole
62
Name an antacid?
Ranitidine
63
How do PPIs work?
Inhibiting the stomach's H+/K+ ATPase proton pump of gastric parietal cells
64
How do antacids work?
Antacids contain alkaline ions that chemically neutralize stomach gastric acid, reducing damage to the stomach lining and esophagus, and relieving pain
65
What do gastric chief cells secrete?
Pepsinogen, and endopeptidase (activated into pepsin by HCl) Lipase
66
What do mucous cells in the stomach secrete?
Mucin, protects stomach lining against acid
67
What compounds and hormones does the stomach secrete and by what cells?
Gastric chief cells: pepsin and lipase Mucous cells: mucin Parietal cells: intrinsic factor and hydrochloric acid G cells: gastrin
68
Where in the stomach can you find the most chief cells?
Middle or superior portion of the stomach
69
Where in the stomach can you find the most G cells?
Antrum (inferior)
70
What is a hiatal hernia?
A hiatal hernia is a type of hernia in which abdominal organs (typically the stomach) slip through the diaphragm into the middle compartment of the chest
71
What are complications following a hiatal hernia?
This may result in gastroesophageal reflux disease (GERD) or laryngopharyngeal reflux (LPR) Iron deficiency anaemia
72
What are the symptoms of a hiatal hernia?
Taste of acid in the back of the mouth, heartburn, trouble swallowing
73
How would you manage a hiatal hernia?
Weightloss, medication (PPI), raising the head of the bed
74
How would you diagnose a hiatal hernia?
Endoscopy | CT
75
What are oesophageal varices?
Esophageal varices are extremely dilated sub-mucosal veins in the lower third of the esophagus
76
What are oesophageal varices often caused by?
Portal hypertension, often due to cirrhosis
77
Why do oesophageal varices only occur in the lower third of the oesophageal?
The upper two thirds of the oesophagus are drained via the oesophageal veins, which carry deoxygenated blood from the oesophagus to the azygos vein, which in turn drains directly into the superior vena cava The lower one third of the oesophagus is drained into the superficial veins lining the oesophageal mucosa, which drain into the left gastric vein, which in turn drains directly into the portal vein
78
What is the most prominent histological feature of oesophageal varices?
Dilated submucosal veins
79
How you manage oesophageal varices in an acute setting?
Aim is to stop blood loss: banding Fluid resuscitation of necessary Secondary prevention with beta-blockers and nitrates
80
What is caput medusae?
Caput medusae is the appearance of distended and engorged superficial epigastric veins, which are seen radiating from the umbilicus across the abdomen
81
What is caput-medusae a sign of?
Portal hypertension
82
What digestive enzymes does the pancreas secrete?
1. Ductal cells --> bicarbonate, neutralise stomach acid 2. Acinar cells -> inactive enzymes (stimulated by CCK in intestine) 3. Delta cells --> somatostatin
83
What does enzymes pancreatic juice contain?
``` Trypsinogen Chymotrypsinogen Carboyxopeptidase Lipase Nucleases Amylase ```
84
What enzymes does the duodenum secrete?
Secretin (by S cell) to stimulate pancreatic ductal cells and HCO3 production Cholecystokinin (I cells), response to high fat and stimulates pancreatic acinar cells Gastric inhibitory peptide (mucosal cells), decreases gastric emptying Somatostatin (mucosal cells), major inhibition Motilin: increases GI motility

3. Inflammation (21 decks)

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