Peptic Ulcer Disease

Question 1

What are the common causes of Peptic Ulcer Disease?

Answer 1

H. Pylori infection (90% duodenal, 70% gastric)
NSAIDs (30% ulcers)
Zollinger-Ellison Syndrome
Smoking/coffee consumption, hepatic/renal failure)
Steroids
Bisphosphonates

Question 2

What is Zollinger-Ellison syndrome?

Answer 2

Excessive acid secretion due to gastrin secreting islet cell tumour

Question 3

What are the presenting sx of Peptic Ulcer Disease?

Answer 3

Eigastric pain (related to food intake, relieved by antacids)
   -Duodenal (pain relieved by eating)
   -Gastric (pain worse on eating)
Nausea
Anorexia/Wt loss
Haematemesis- coffee ground vomit
Malaena

Question 4

What investigations are appropriate in suspected Peptic Ulcer Disease?

Answer 4

None needed if <55/no ALARM sx/resolves on GORD rx
Urgent OGD (if ALARMS 55 criteria met)
H. pylori ix

Question 5

What investigations can be used to confirm an infection w/ H. Pylori?

Answer 5

13C Urea Breath Test
Gastric biopsies (colour change w/ phenol red urea solution)

Question 6

Describe the 13C Urea Breath Test

Answer 6

Pt ingests 13C labelled urea
If H. Pylori present urease enzyme produces 13CO2
This can be detected on the breath

Question 7

What are the key distinguishing features of duodenal ulcers?

Answer 7

4x more common than gastric ulcers
90% w/i 2cm of pylorus
Pain at night/before meals, relieved by food/milk
Alcohol intake as risk factor

Question 8

What are the key distinguishing features of gastric ulcers?

Answer 8

Older pts (>55)
On lesser curve of stomach
Pain worse on eating, relieved by antacids

Question 9

What are the pathological consequences of H. Pylori infection on PUD?

Answer 9

Gastritis (mainly in antrum) causing inflammatory infiltrate
Increased acid secretion & abnormal mucus production –> epithelial damage
Can cause atrophic gastritis –> metaplasia

Question 10

What are the pathological consequences of smoking on PUD?

Answer 10

Impairs gastric mucosal healing

Nicotine increases acid secretion

Question 11

What are the pathological consequences of NSAIDs on PUD?

Answer 11

NSAIDs inhibit COX enzymes (anti-inflammatory)
-adverse GI effects due to COX-1 inhibition
Steroids also have this effect

Question 12

How can the pathological consequences of NSAIDs on PUD be avoided?

Answer 12

Co-administration of PPIs/PG analogues

Question 13

What are the management options for PUD, if ALARMS 55 sx not present?

Answer 13

Lifestyle measures (avoid food that worsens sx, stop smoking)
High dose PPI or H2 receptor antagonist for 6-8wks
Stop NSAIDs

Question 14

What are the management options for PUD, if H. Pylori is present?

Answer 14

Triple therapy

-PPI + amoxicillin/metronidazole PLUS clarithromycin

Question 15

When is surgical management for PUD used?

Answer 15

Pts who cannot tolerate medical therapy
Gastrectomy in Zollinger-Ellison
Perforation

Question 16

What are features of Peptic ulcer perforation, what investigations are needed and what is the management?

Answer 16

Widespread abdo pain
Haemodynamically unstable
Peritonism

Need CXR to look for air under diaphragm

Urgent surgical repair

Question 17

What are features of peptic ulcer bleed?

Answer 17

Haematemesis

Malaena

Question 18

What are ALARM 55 features?

Answer 18

Patient >55 with weight loss and any one of
Abdo pain
Dyspepsia
Acid reflux

Require 2ww endoscopy