Peptic Ulcer Disease

Question 1

What are peptic ulcers?

Answer 1

Break in the lining of the GI tract extending through the muscular layer (maculararis mucosae). It is an endoscopic diagnosis.

Most common in the lesser curvature of the proximal stomach or the first part of the duodenum.

Duodenal ulcers classically present a lot earlier then gastric.

Question 2

What are the risk factors of peptic ulcers?

Answer 2

H.pylori infection and prolonged NSAIDs use are the two most common.

Corticosteroid use(when used with NSAIDs) 
Previous gastric bypass surgery 
Physiological stress (severe burns(Curlings ulcer) or head trauma(Cushings ulcer))
Zollinger-Ellison syndrome (rare)

Question 3

What are the typical clinical features of peptic ulcers?

Answer 3

Asymptomatic- 70%

Epigastric or retrosternal pain, nausea, bloating, post-prandial discomfort or early satiety

Classically gastric ulcers - pain exacerbated by eating and duodenal ulcer worse 2-4 hrs after eating or even alleviated by eating.

Question 4

What are some less common presentation of some with peptic ulcer?

Answer 4

Complications - bleeding, perforation or gastric outlet obstruction

Question 5

What are the urgent referral criteria for upper OGD?

Answer 5

• new onset Dysphagia
• aged >55 years with weight loss and either upper abdominal pain, reflux, or dyspepsia
• new onset dyspepsia not responding to PPI treatment

Question 6

What are the differential diagnosis for peptic ulcer disease?

Answer 6

ACS 
GORD
Gallstone disease 
Gastric malignancy 
Pancreatitis

Question 7

What is Zollinger-Ellison syndrome?

Answer 7

Triad of (i) severe peptic ulcer disease (ii) gastric acid hyper-secretion (iii) gastrinoma 
Characteristic finding gastrin level >1000pg/ml 

1/3 of cases discovered as part of Multiple Endocrine Neoplasia (MEN) type 1 syndrome (Pancreas/pituitary/parathyroid), so further investigations for MEN syndrome are often warranted.

Question 8

What are the initial investigations for peptic ulcer disease?

Answer 8

Treated empirically - OGD not required for many
FBC to assess for anaemia

Most pts: non-invasive H.Pylori testing (should stop any current medication for 2 weeks to reduce false negatives)

• carbon-13 urea breath test
• serum antibodies to H.pylori
• stool antigen test

Question 9

When is OGD required in peptic ulcer disease?

Answer 9

Older pts or those with red flag symptoms or ongoing symptoms despite empirical treatment

Biopsy should be taken if peptic ulceration seen and sent for histology (malignant potential) and rapid urease test (H.pylori presence)

Repeat endoscopy is performed at end of PPI therapy to check for resolution

Question 10

What is the conservative management of peptic ulcer disease?

Answer 10

Lifestyle advice - smoking cessation, reduce alcohol consumption, weight loss and avoid NSAIDs.

PPI for 4-8 week and reassess if resolution of symptoms

Pts with positive H.pylori should be started of triple therapy.

Persistent symptoms warrants OGD

Question 11

What is the triple therapy for H.pylori?

Answer 11

PPI + oral amoxicillin and clarithromycin or metronidazole(if allergic to penicillin) for 7 days

Question 12

What are the surgical management for peptic ulcer disease and when are they used?

Answer 12

Rare expect in emergencies e.g. perforation
Can be used in severe or relapsing disease

Include:
Partial gastrectomy
Selective vagotomy

Question 13

What are the complications of peptic ulcer disease?

Answer 13

Perforation
Haemorrhage
Pyloric stenosis - rare