Peptic Ulcer Disease Flashcards
Name 4 factors that protect the gastric mucosa
• Bicarb
• blood flow
• prostaglandins
• mucus
Name 4 factors that damage the gastric mucosa
• H pylori
• gastric acid
• pepsin
• NSAIDs
Name 8 factors that increase gastric acid production
• H pylori infection in antrum: H pylori produces urease enzyme which breaks down urea to ammonia → alkalinisation of mucosa. This stimulates production gastrin
• Antral G-cell hyperplasia and G-cell adenoma (gastrinoma): zollinger Ellison syndrome
. Diet: spicy food, coffee, tea, chocolate
. Alcohol
• cigarette
• systemic steroids
. NSAIDs (inhibit protective prostaglandin)
• physiological stress eg severe burns, head injury
Name the 3 most common sites of benign peptic ulceration
• First part duodenum
• pyloric antrum
• lesser gastric curvature
Name the 4 less common sites of benign peptic ulceration
• Distal esophagus
• distal duodenum
• stomach ulcer
• Meckel’s diverticulum
Symptoms gastric peptic ulcers? (4)
•Most asymptomatic
• dyspepsia
• postprandial epigastric pain!
• May cause avoidance food → weight loss
Symptoms duodenal peptic ulcers? (5)
• Most asymptomatic
• Dyspepsia
• epigastric pain on fasting!
• pain may wake patient up at night, relieved by feeding
• may lead to weight gain
Complications peptic ulcers? (5)
• Perforation: esophageal perforation into mediastinum rare, gastric and duodenal perforation freely into peritoneal cavity
• bleeding: Frank acute from penetration onto blood vessels in bed of outer, or erosion of submucosal vascular plexus leading to slow chronic loss → iron deficiency anemia
• Gastric outlet obstruction: from fibrotic stricture from previous ulcer, or from edema from active ulcer
• esophageal stricture: from fibrotic scarring of previous ulcer , may be associated with develop epiphrenic diverticulum due to weakness in muscle wall and increased intraluminal pressure
• Fistula: gastro-colic, biliary- gastrointestinal (choledocho or cholecysto gastric or duodenal)
Symptoms perforated peptic ulcer? (2)
Acute abdomen.
• sudden onset abdominal pain that starts in epigastrium or RUQ and rapidly spreads to rest of abdomen
• May be symptom free lucid interval from dilution effect initial chemical peritonitis by inflammatory exudate followed later by septic peritonitis
Clinical presentation perforated peptic ulcer ? (8)
• Varying degrees of septic shock
• Tachycardia
• fever
• hypotension
• increased respiratory rate
. Generalised abdominal tenderness
• board like rigidity (peritonitis)
• localised pus collections, rarely pleural abscess
Diagnostic investigations perforated peptic ulcer? (5)
• Erect cxr: free intra-abdominal gas in 75% (90% on insufflation with air via NGT )
• erect AXR: paralytic ileus with fluid levels
• ultrasound to rule out gallstones
• CT abdomen if not certain: pus collections
• FCC, CRP for inflammation; lipase amylase to exclude acute pancreatitis especially if no free intra-abdominal gas
Name 4 indications non-surgical management perforated peptic ulcer
• Minimal abdominal signs but clear
• radiographic signs of perforation (rare )
• severe shock with comorbidities
• surgery contraindicated eg elderly with COPD, CCF
non-surgical management perforated peptic ulcer?
•
multiple ultrasound guided percutaneous drains
• send pus for MCs
• broad spectrum antibiotics (augmentin) and tailor later
surgical management perforated peptic ulcer?
OMental patch (omentopexy) with 6 biopsies, via upper midline laparotomy or laparoscopy
Rinse thoroughly >6 L warm water
First line therapy H pylori eradication?
• Ppl
• clarithromycin
• amoxicillin or metronidazole 7-14 days
Describe Forrest classification of bleeding peptic ulcer
On endoscopy. Do Within 24 hours.
• Forrest 1: active haemorrhage
A: spurting, high risk rebleed on medical treatment only
Bi oozing
• Forrest 2: signs recent haemorrhage
A: non-bleeding visible vessel, high risk rebleed on medical treatment only
Bi adherent clot
C: coffee ground on ulcer base
• Forrest 3: no signs recent haemorrhage, clean user base, covered with fibrin
Treatment persistently bleeding peptic ulcers? (7)
• Endoscopic - use more than 1 modality
- saline or adrenaline injection (thrombosis)
- thermal coagulation
- argon laser coagulation
- clip application
• surgical homeostasis lap/open: under run or oversew with Figure of 8 suture
• angiographic embolisation
• full ppl and H pylori post op with 6 week follow up to confirm ulcer Heal
Definitive treatment gastric outlet obstruction due to peptic ulcer? (7)
• Keep NPO, TPN 10-12 days
• iv ppl 10-12 days
• trial oral clear fluid after 10-12 days.if tolerate graduate to mixed fluids then fluid diet. If not tolerated, suggests fibrotic stricture ( as opposed to oedematous)
• endoscopic balloon dilatation with or withouttemporary self retaining stent and retrieve in 7-10 days.
• #f fail due to dilute fibrotic stricture → surgery pyloroplasty
• if fail → antrectomy with gastro-duodenal anastomosis
Post op ppl and H pylori eradication, follow up in 6 weeks
