Peptic ulcer disease

Question 1

Peptic ulcers

Answer 1

involve ulceration of the mucosa lining the stomach (gastric ulcer) or the duodenum (duodenal ulcers)

Question 2

Which type of ulcer is more common?

Answer 2

Duodenal ulcers - 4x more common than gastric ulcers

Question 3

Pathophysiology of PUD

Answer 3

Stomach mucosa is prone to ulceration from:
Breakdown of the protective layer of the stomach and duodenum
Increase in stomach acid

Question 4

What is the protective layer of the stomach mucosa comprised of?

Answer 4

Mucus and bicarbonate

Question 5

What breaks down the protective layer?

Answer 5

Medications e.g. steroids & NSAIDs

Helicobacter pylori

Question 6

Increased acid can result from:

Answer 6

Stress 
Alcohol
Caffeine 
Smoking 
Spicy foods

Question 7

What is the usual presentation of PUD

Answer 7

Non-specific

Epigastric pain/ discomfort
Dyspepsia
Nausea & vomiting
Bleeding causing haematemesis - “coffee ground” vomit or haematemesis
Iron deficiency anaemia due to constant bleeding

Question 8

Classification of PUD:

Answer 8

Acute: usually due to drugs (NSAIDs or steroids) or “stress”
Chronic: drugs, H.pylori, hypercalcaemia, Zollinger-Ellison

Question 9

Duodenal ulcers are more common in:

Answer 9

M >F

occur in the 1st part of the duodenum

Question 10

Gastric ulcers occur:

Answer 10

in the lesser curve of the gastric antrum

Question 11

Risk factors for duodenal ulcers:

Answer 11

H.pylori (90%)
Drugs - NSAIDs, steroids
Smoking
Alcohol 
Increased gastric emptying 
Blood Group O

Question 12

Risk factors for gastric ulcers:

Answer 12

H.pylori (80%)
Smoking 
Drugs 
Delayed gastric emptying 
Stress: 
- Cushing's: intracranial disease 
- Curling's: burns, sepsis, trauma

Question 13

Presentation of duodenal ulcers:

Answer 13

Epigastric pain
Worse before meals and at night
Improved by eating or drinking milk

Question 14

Presentation of gastric ulcers

Answer 14

Epigastric pain
Worse after eating
Relieved by antacids
Weight loss

Question 15

Complications of peptic ulcers

Answer 15

Haemorrhage - haematemesis/ melaena - can be life threatening
Perforation - causing peritonitis
Gastric outflow obstruction - scarring and strictures –> pyloric stenosis –> difficulty emptying stomach contents –> distension, colic, nausea and vomiting
Malignancy - increased risk associated with H.pylori

Question 16

Investigations for PUD

Answer 16

Bloods: FBC, urea (increased in haemorrhage)
C13 breath test/ rapid urease test (CLO test)
OGD - stop PPI/H2RA 2 weeks before
- always take biopsies of the ulcers to rule out malignancy
Gastrin levels if Zollinger-Ellison suspected

Question 17

Conservative management of PUD

Answer 17

Lose weight 
Stop smoking and reduce alcohol intake 
Avoid hot drinks and spicy foods
Stop drugs: NSAIDs and steroids
OTC antacids

Question 18

Medical management of PUD

Answer 18

Same as GORD 
OTC antacids: Gaviscon, Mg trisilicate 
H.pylori eradication PAC500 or PMC250
Full dose PPI for 1-2mo
- PPI lansaprazole 30mg OD 
- H2RAs: ranitidine 300mg nocte 
Low dose acid suppression PRN

Question 19

Surgery for PUD: what are the key concepts?

Answer 19

No acid –> no ulcer

Secretion of the acid is stimulated by gastrin and vagus nerve

Question 20

What are the types of surgery used for PUD?

Answer 20

1. Vagotomy:
   - Truncal - reduced acid secretion but prevents pyloric sphincter relaxation therefore must be combined with pyloroplasty
   - Selective: vagus nerve only denervated where it supplies lower oesophagus and stomach - Nerves of laterjet, supply pylorus, left intact
2. Anterectomy with vagotomy
   - distal half of the stomach removed and anastomosed with duodenum = Biliroth 1
   - to small bowel loop with duodenal stump oversewn = Biliroth 2 or polya
3. Sub-total gastrectomy with Roux en Y
   - occasionally performed for Zollinger-Ellison

Question 21

What are the physical complications of PUD surgery?

Answer 21

Stump leakage
Abdominal fullness
Reflux or bilious vomiting (improves with time)
Stricture

Question 22

What are the metabolic complications of PUD surgery?

Answer 22

Dumping syndrome - abdo distension, flushing, n/v
- Early: osmotic hypovolaemia
- Late: reactive hypoglycaemia
Blind loop syndrome - malabsorption, diarrhoea
- overgrowth of bacteria in the duodenal stump
- anaemia: Fe + B12
- osteoporosis
Weight loss: malabsorption of reduced calorie intake