Peptic ulcer disease Flashcards
What is peptic ulcer disease?
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
What are common causes of peptic ulcer disease?
H. pylori
NSAID use
Less common include tobacco, smoking, stress
Who is most sensitive to developing peptic ulcer disease after NSAID use?
Older people
What are the signs and symptoms of peptic ulcer disease?
Abdominal (mainly epigastric) pain Bloating Nausea Heartburn Blood in stool
What is the effect of eating on the pain in peptic ulcer disease?
Gastric ulcer –> worse
Duodenal ulcer –> better
What are the risk factors for developing peptic ulcer disease?
Heartburn
Gastroesophageal reflux disease
NSAID use
What are the complications of peptic ulcer disease?
Gastrointestinal bleeding (can be lethal! Most common)
Perforation
Cancer (H. pylori)
What do parietal cells secrete?
HCl
Intrinsic factor
What do G cells release?
Gastrin, stimulate parietal cells
NSAIDs can increase the risk of peptic ulcer disease. What other medications, taken with aspirin, increase this risk?
Aspirin SSRIs Corticosteroids Antimineralocorticoids Anticoagulants
How do NSAIDs increase the risk of peptic ulcer disease?
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.
How is peptic ulcer disease diagnosed?
Characteristic symptoms:
1. Stomach pain
Esophagogastroduodenoscopy
Potentially Barium swallowing
What layer do peptic ulcers affect?
Muscularis mucosae and lamina propria
how can you diagnose the presence of H. pylori?
Urea breath test, as H. pylori secretes urease
Culture from endoscopy
Rapid urease test
What is the macroscopic appearance of peptic ulcers?
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
What is the microscopic appearance of peptic ulcers?
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
How can you prevent peptic ulcers?
PPI with NSAIDs
How would you manage H. pylori induced peptic ulcer disease?
A triple regimen in which pantoprazole and clarithromycin are combined with either amoxicillin or metronidazole. 7-14 days
How would you manage NSAID induced peptic ulcer disease?
NSAID-associated ulcers heal in 6 to 8 weeks provided the NSAIDs are withdrawn with the introduction of proton pump inhibitors
What is the Glasgow-Blatchford score?
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
What criteria are considered in the Glasgow-Blatchford score?
Blood urea Haemoglobin Systolic blood pressure Pulse Melaena (dark stool) Syncope Hepatic disease Cardiac failure
What is the Rockall score?
Identifies patients at risk of adverse outcome following acute upper gastrointestinal bleeding.
What criteria are considered in the Rockall score?
Age Shock Co-morbidity Diagnosis Evidence of bleeding
How do you notice upper gastrointestinal bleeding?
Blood in vomit
Black stool
Hypovolaemic shock
What are upper gastrointestinal bleedings caused by?
Peptic ulcers
Gastric erosions
Esophageal varices
Mallory-Weiss tear
What are the signs in upper gastrointestinal bleeding?
Vital signs are deteriorating quickly: a medical emergency!
What is the prognosis for uppper gastrointestinal bleeds?
Depending on its severity, upper gastrointestinal bleeding may carry an estimated mortality risk of 11%
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
How would you manage someone with acute gastrointestinal bleeding who is taking warfarin?
Offer prothrombin complex concentrate
How would you manage non-variceal bleeding?
After stabilisation!
For the endoscopic treatment of non-variceal upper gastrointestinal bleeding, use one of the following:
- a mechanical method (for example, clips) with or without adrenaline
- Thermal coagulation with adrenaline
- Fibrin or thrombin with adrenaline
DO NOT offer PPI before endoscopy
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
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
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
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
What is a Mallory Weiss tear?
Bleeding from a laceration in the mucosa at the junction of the stomach and esophagus
What are Mallory Weiss tears usually caused by?
Alcoholism
Bulimia
Any other cause of vomiting
What are Mallory Weiss tears signs and symptoms?
Vomiting blood
Blood in stool
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
How would you diagnose a Mallory Weiss tear?
Endoscopy
What is Boerhaave syndrome?
A full thickness oesophageal rupture due to vomiting
What are signs and symptoms of esophageal rupture?
History of retching and vomiting, immediately followed by excruciating retrosternal chest and upper abdominal pain
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
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
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)
What is the difference between Boerhaave’s syndrome and a Mallory-Weiss tear?
Boerhaave: full oesophageal rupture
Mallory-Weiss: mucosal tear
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.
What microscopic change can be seen in Barret’s oesophagus?
stratified squamous epithelium to simple columnar epithelium with interspersed goblet cells
What are risk factors of Barrett’s oesophagus?
Oesophageal adenocarcinoma
What is the main cause of Barret’s oesophagus?
Adaptation to chronic exposure from acid reflux
How would you diagnose Barret’s oesophagus?
Endoscopy and biopsy
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
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
What are the symptoms of Barret’s oesophagus?
Heartburn
Dysphagia
Vomiting blood
Pain under sternum
What is Gastroesophageal reflux disease (GERD)?
A chronic condition in which stomach contents rise up into the esophagus, resulting in either symptoms or complications
What are the signs and symptoms of gastroesophageal reflux disease (GERD)?
Acidic taste in the mouth Regurgitation Heartburn Pain with swallowing Chest pain
What are the complications following gastroesophageal reflux disease (GERD)?
Complications include esophagitis, esophageal stricture, and Barrett’s esophagus
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.
What is the problem in gastroesophageal reflux disease (GERD)?
Mechanical: poor closure of the lower oesophageal sphincter
How is gastroesophageal reflux disease (GERD) diagnosed?
Symptoms Endoscopy (and biopsy)
How is gastroesophageal reflux disease (GERD) managed?
Lifestyle: less coffee, acidic, spicy food. Weight loss
Medication: PPI and antacids
Surgery
Name a proton-pump inhibitor?
Omeprazole
Name an antacid?
Ranitidine
How do PPIs work?
Inhibiting the stomach’s H+/K+ ATPase proton pump of gastric parietal cells
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
What do gastric chief cells secrete?
Pepsinogen, and endopeptidase (activated into pepsin by HCl)
Lipase
What do mucous cells in the stomach secrete?
Mucin, protects stomach lining against acid
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
Where in the stomach can you find the most chief cells?
Middle or superior portion of the stomach
Where in the stomach can you find the most G cells?
Antrum (inferior)
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
What are complications following a hiatal hernia?
This may result in gastroesophageal reflux disease (GERD) or laryngopharyngeal reflux (LPR)
Iron deficiency anaemia
What are the symptoms of a hiatal hernia?
Taste of acid in the back of the mouth, heartburn, trouble swallowing
How would you manage a hiatal hernia?
Weightloss, medication (PPI), raising the head of the bed
How would you diagnose a hiatal hernia?
Endoscopy
CT
What are oesophageal varices?
Esophageal varices are extremely dilated sub-mucosal veins in the lower third of the esophagus
What are oesophageal varices often caused by?
Portal hypertension, often due to cirrhosis
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
What is the most prominent histological feature of oesophageal varices?
Dilated submucosal veins
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
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
What is caput-medusae a sign of?
Portal hypertension
What digestive enzymes does the pancreas secrete?
- Ductal cells –> bicarbonate, neutralise stomach acid
- Acinar cells -> inactive enzymes (stimulated by CCK in intestine)
- Delta cells –> somatostatin
What does enzymes pancreatic juice contain?
Trypsinogen Chymotrypsinogen Carboyxopeptidase Lipase Nucleases Amylase
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
