Peptic Ulcer Disease

Question 1

Peptic ulcer disease (PUD) is an umbrella term for the development of two different ulcers: … ulcers and … ulcers.

Answer 1

Peptic ulcer disease (PUD) is an umbrella term for the development of two different ulcers: gastric ulcers and duodenal ulcers.

Question 2

Peptic ulcer disease is a relatively common condition that frequently presents with …, abdominal discomfort and …. It can be complicated by perforation, haemorrhage and gastric outlet obstruction.

Answer 2

PUD is a relatively common condition that frequently presents with dyspepsia, abdominal discomfort and nausea. It can be complicated by perforation, haemorrhage and gastric outlet obstruction.

Question 3

It is important to understand the difference between ulcers and erosions:

Answer 3

Erosion - superficial/partial break within the epithelium or mucosal surface.
Ulcer - deep break through the full thickness of the epithelium or mucosal surface.

Question 4

The most commonly identified aetiological factors for peptic ulcer disease are … (2)

Answer 4

The most commonly identified aetiological factors are H.pylori infection and NSAID use. Upper GI endoscopy is used for diagnosis whilst management consists of H.pylori eradication therapy (when indicated), proton-pump inhibitors and lifestyle and risk-factor modification.

Question 5

There is an estimated lifetime prevalence of …-…% for peptic ulcer disease

Answer 5

There is an estimated lifetime prevalence of 5-10% for peptic ulcer disease

Question 6

Gastric ulcers: Incidence … with age with equal gender distribution.

Answer 6

Gastric ulcers: Incidence increases with age with equal gender distribution.

Question 7

Duodenal ulcers: Appear to be more common in … with incidence that peaks between the ages of 45-64.

Answer 7

Duodenal ulcers: Appear to be more common in men with incidence that peaks between the ages of 45-64.

Question 8

The majority of peptic ulcers are related to … infection.

Answer 8

The majority of peptic ulcers are related to H.pylori infection.

Question 9

…. is by far the most commonly implicated aetiological factor associated with approximately 95% of duodenal ulcers and 70-80% of gastric ulcers. Medications may predispose to PUD with … the most important agents. Others include corticosteroids, bisphosphonates and SSRI’s.

Answer 9

H.pylori is by far the most commonly implicated aetiological factor associated with approximately 95% of duodenal ulcers and 70-80% of gastric ulcers. Medications may predispose to PUD with NSAIDS the most important agents. Others include corticosteroids, bisphosphonates and SSRI’s.

Question 10

H. pylori is a gram … spiral-shaped, flagellated, micro-aerophilic bacterium, which is thought to colonise up to 50% of the world’s population.

Answer 10

H. pylori is a gram negative spiral-shaped, flagellated, micro-aerophilic bacterium, which is thought to colonise up to 50% of the world’s population.

Question 11

The infection is more common in the developing world and usually acquired during childhood. It is estimated that up to 95% of patients with … are infected with H. pylori, yet only 15% of patients with H. pylori will develop …. H. pylori predominantly colonise the antrum of the stomach, which is the least acidic. Colonisation of the gastric antrum can lead to persistent low-grade inflammation.

Answer 11

The infection is more common in the developing world and usually acquired during childhood. It is estimated that up to 95% of patients with PUD are infected with H. pylori, yet only 15% of patients with H. pylori will develop PUD. H. pylori predominantly colonise the antrum of the stomach, which is the least acidic. Colonisation of the gastric antrum can lead to persistent low-grade inflammation.

Question 12

H. pylori has been associated with a number of GI …. The exact pathogenesis are yet to be understood but as many individuals will have H. pylori without any … developing, individual pre-disposing factors are key.

Answer 12

H. pylori has been associated with a number of GI malignancies. The exact pathogenesis are yet to be understood but as many individuals will have H. pylori without any malignancy developing, individual pre-disposing factors are key. The infection has been associated with:

Gastric lymphoma
Gastric adenocarcinoma

Question 13

H pylori associated malignancies: (2)

Answer 13

Gastric lymphoma

Gastric adenocarcinoma

Question 14

NSAIDS inhibition of …-… reduces the production of mucosal protective prostaglandins.

Answer 14

NSAIDS inhibition of COX-1 reduces the production of mucosal protective prostaglandins.

Question 15

NSAIDS inhibition of COX-1 reduces the production of mucosal protective ….

Answer 15

NSAIDS inhibition of COX-1 reduces the production of mucosal protective prostaglandins.

Question 16

COX-…: constitutively expressed, acts as an enzyme to catalyse production of mediators like prostaglandin and thromboxane from arachidonic acid. Important role in many physiological functions including protective effects on the gastric mucosa. It is the somewhat inadvertent inhibition of this system that leads to some NSAID related side effects like gastritis and PUD.

Answer 16

COX-1: constitutively expressed, acts as an enzyme to catalyse production of mediators like prostaglandin and thromboxane from arachidonic acid. Important role in many physiological functions including protective effects on the gastric mucosa. It is the somewhat inadvertent inhibition of this system that leads to some NSAID related side effects like gastritis and PUD.

Question 17

COX-….: inducible expression in response to inflammation. Catalyses production of inflammatory prostaglandins (and other mediators) from arachidonic acid. These prostaglandins play a role in inflammation, pain and fever and it is inhibition of their effects that give the desired symptomatic relief from NSAIDs.

Answer 17

COX-2: inducible expression in response to inflammation. Catalyses production of inflammatory prostaglandins (and other mediators) from arachidonic acid. These prostaglandins play a role in inflammation, pain and fever and it is inhibition of their effects that give the desired symptomatic relief from NSAIDs.

Question 18

It is suspected that 50% of patients taking … show mucosal damage, 30% of patients have ulcers seen on endoscopy and 5% of patients are symptomatic.

Answer 18

It is suspected that 50% of patients taking NSAIDs show mucosal damage, 30% of patients have ulcers seen on endoscopy and 5% of patients are symptomatic.

Question 19

Some newer NSAIDs (e.g. Celecoxib) have been developed that selectively target COX-…. These drugs may be taken in rheumatic disease to help reduce the number of GI side-effects. However use is limited owing to the increased risk of cardiovascular complications.

Answer 19

Some newer NSAIDs (e.g. Celecoxib) have been developed that selectively target COX-2. These drugs may be taken in rheumatic disease to help reduce the number of GI side-effects. However use is limited owing to the increased risk of cardiovascular complications.

Question 20

Z…-E… syndrome occurs secondary to a hyper-secreting gastrinoma within the pancreas.

Answer 20

Zollinger-Ellison syndrome occurs secondary to a hyper-secreting gastrinoma within the pancreas.

Question 21

… leads to the development of multiple peptic ulcers. Sporadic cases account for around 80% of cases of Zollinger-Ellison syndrome.

Answer 21

Hypergastrinaemia leads to the development of multiple peptic ulcers. Sporadic cases account for around 80% of cases of Zollinger-Ellison syndrome.

Question 22

The hallmark features of Peptic ulcer disease are epigastric pain, dyspepsia and heartburn.

Answer 22

The hallmark features of PUD are epigastric pain, dyspepsia and heartburn.

Question 23

Symptoms of peptic ulcer disease:

Answer 23

Epigastric pain
Dyspepsia (e.g. distension, bloating)
Heartburn

Question 24

Signs of peptic ulcer disease:

Answer 24

Mild epigastric tenderness

Question 25

These are signs and symptoms of what?

Answer 25

Peptic ulcer disease

Question 26

Acute presentations of peptic ulcer disease:

Answer 26

Patients with PUD may present acutely with features of an acute upper GI bleed (UGIB) or perforation.

Question 27

Patients with PUD may present acutely with features of an acute upper GI bleed (UGIB) or perforation
What are the signs and symptoms?

Answer 27

Acute UGIB
Haematemesis +/- melaena
Features of shock may be present
Perforation
Acute, severe abdominal pain & tenderness
Localised or generalised guarding
Features of shock may be present

Question 28

Gastric … … may occur in PUD secondary to stricturing and narrowing resulting from inflammation, ulcers and scarring.

Answer 28

Gastric outlet obstruction may occur in PUD secondary to stricturing and narrowing resulting from inflammation, ulcers and scarring.

Question 29

Gastric outlet obstruction may occur in PUD secondary to stricturing and narrowing resulting from inflammation, ulcers and scarring.

Patients present with …, … and typically … abdominal pain. Tenderness, distention and a succussion splash may be found on examination.

Answer 29

Patients present with nausea, vomiting and typically upper abdominal pain. Tenderness, distention and a succussion splash may be found on examination.

Question 30

The definitive diagnosis of PUD is made on … examination. However, only a small number of patients presenting with dyspepsia/heartburn require this.

Answer 30

The definitive diagnosis of PUD is made on endoscopic examination. However, only a small number of patients presenting with dyspepsia/heartburn require upper GI endoscopy.

Question 31

Bedside tests for peptic ulcer disease

Answer 31

Observations
H. pylori testing (see below)
ECG (cardiac pathology should be considered in patients presenting with epigastric pain/discomfort)

Question 32

Blood tests for peptic ulcer disease

Answer 32

Full blood count (may show an iron-deficiency anaemia)

Liver function tests (may be ordered if biliary pathology and gallstones a suspected differential)

Question 33

What endoscopy is done for peptic ulcer disease?

Answer 33

Upper GI endoscopy

Question 34

H. pylori testing for peptic ulcer disease - is it invasive or not?

Answer 34

H. pylori testing may be non-invasive or invasive.

Non-invasive tests offer good sensitivity and specificity when used in the correct setting. Invasive testing may be completed during an upper GI endoscopy.

Question 35

Non-invasive H-pylori testing in Peptic ulcer disease:

Answer 35

C Urea breath test: Is a useful screening test for the presence of H. pylori. The subject ingests 13C urea, which is converted to 13CO2 in the presence of urease. It is a highly sensitive 97.6% and specific (96%) test. The breath test can be used for both diagnosis and testing for eradication. Importantly, patients must be off PPI’s prior to testing.

Serological test: A blood test is taken which checks IgG antibodies against H. pylori. This is a useful test for diagnosis and epidemiological studies. In general, it is a good test (sensitivity 90% and specificity of 83%). However, it cannot be used to check for eradication owing to the persistence of antibodies within the serum.

Stool antigen test: The stool test assesses the faeces for the presence of H. pylori antigen. It is a reliable test (sensitivity 97.6% and specificity 96%), and can be used for both diagnosis and testing for the eradication of H. pylori. Like the breath test, patients must be off PPI’s prior to testing.

Question 36

Invasive H-pylori testing in Peptic ulcer disease:

Answer 36

Urease test: The urease test is also known as the CLO test (campylobacter-like organism test). Biopsies are taken from the mucosa during endoscopy and added to a medium containing phenol red and urea. The presence of urease leads to the splitting of urea, and the release of ammonium that leads to a pH colour change. The test may be falsely negative in the presence of PPI therapy.

Histology: A section of a biopsy taken during endoscopy can be examined under a microscope with a Giemsa stain looking for the organism.

Culture: A biopsy specimen taken at the time of endoscopy can be used for culture of the organism. This test is useful for assessment of antibiotic sensitivities.

Question 37

Management of peptic ulcer disease:

Answer 37

Management of PUD involves lifestyle modifications, PPIs and antibiotics.

Patients who test positive for H. pylori should be offered eradication therapy. The length of treatment (and need for specialist intervention) is dependent on H. pylori status, NSAID involvement and symptomatic control.

Question 38

Patients who test positive for H. pylori should be offered … therapy. The length of treatment (and need for specialist intervention) is dependent on H. pylori status, NSAID involvement and symptomatic control.

Answer 38

Patients who test positive for H. pylori should be offered eradication therapy. The length of treatment (and need for specialist intervention) is dependent on H. pylori status, NSAID involvement and symptomatic control.

Question 39

What is key to the management of PUD?

Answer 39

Lifestyle modifications are key to the management of PUD. Patients should maintain a healthy diet avoiding foods and drinks that exacerbate their symptoms.

Question 40

Peptic ulcer disease: lifestyle modifications

Answer 40

Avoid triggers: Patient may encounter certain foods that trigger discomfort and pain, common examples include coffee, tomato and spicy foods.
Obesity: In patients who are overweight help and advice for healthy weight-loss should be given.
Smoking & alcohol: Where appropriate smoking cessation advice and help should be given. Alcohol should be reduced where necessary and within the national advised limits.
Mental health: Assess the patients for any psychological conditions such as anxiety or depression that may impact on symptoms.

Question 41

PUD associated with H.pylori - treatment

Answer 41

No association with NSAIDs: Patients are given the first-line eradication therapy.
Association with NSAIDs: Patients are given two months of full-dose PPI, after this is complete they are given first-line eradication therapy.

Question 42

PUD not associated with H.pylori - treatment

Answer 42

Patients who test negative for H.pylori are given 4-8 weeks of full-dose PPI.

Question 43

Due to the possibility of underlying malignancy, … ulcers should be biopsied and reassessed after treatment. This means a follow-up endoscopy to ensure healing in 6-8 weeks. … ulcers do not routinely require follow-up endoscopy.

Answer 43

Due to the possibility of underlying malignancy, gastric ulcers should be biopsied and reassessed after treatment. This means a follow-up endoscopy to ensure healing in 6-8 weeks. Duodenal ulcers do not routinely require follow-up endoscopy.

Question 44

H. pylori eradication therapy needs to take into account previous antibiotic therapy and patient ….

Answer 44

H. pylori eradication therapy needs to take into account previous antibiotic therapy and patient allergies.

Question 45

1st line eradication for H-pylori in peptic ulcer disease:

Answer 45

Patients are given a 7-day course of triple-therapy, which includes a PPI and dual antibiotic therapy.

Non-penicillin allergy:
Proton pump inhibitor
Amoxicillin
Clarithromycin/metronidazole
Penicillin allergy:
Proton pump inhibitor
Clarithromycin
Metronidazole

Question 46

2nd line eradication for H-pylori in peptic ulcer disease:

Answer 46

If 1st line therapy fails patients are given a different antibiotics and an extended course. The choice of pharmacotherapy is dependent on allergy status and previous antibiotic exposure.

Non-penicillin allergy:
Proton pump inhibitor
Amoxicillin
Clarithromycin/metronidazole
Quinolone/tetracycline

Penicillin allergy:
PPI
Metronidazole
Levofloxacin/tetracycline
Bismuth

Question 47

Peptic ulcer disease may be complicated by …, h… and gastric outlet obstruction.

Answer 47

Peptic ulcer disease may be complicated by perforation, haemorrhage and gastric outlet obstruction.

Question 48

Complications of peptic ulcer disease: perforation

Answer 48

Perforation: Due to earlier recognition and treatment the incidence of PUD related perforations has decreased though it remains a life-threatening condition with a mortality of up to 20%. Patients typically present with severe abdominal pain with signs of infection. Management tends to take the form of supportive care, antibiotics and laparoscopic repair / omental patch.

Question 49

Complications of peptic ulcer disease: haemorrhage

Answer 49

Haemorrhage: Can cause a massive upper GI bleed, a life-threatening condition with mortality estimated to be 5-10%. The classical description of bleeding in PUD is of a posterior duodenal ulcer eroding through into the gastroduodenal artery. However many occur secondary to erosions through smaller-sized blood vessels within the submucosa. Bleeding may be mild and chronic resulting in iron deficiency anaemia. See our Upper GI bleeding notes for more information.

Question 50

Complications of peptic ulcer disease: gastric outlet obstruction

Answer 50

Gastric outlet obstruction: May occur secondary to inflammation, ulceration and scarring leading to narrowing and stricturing of the gastric outlet. Patients tend to present with nausea and vomiting, abdominal pain and distention.