Peptic Ulcer Disease

Question 1

Name 4 factors that protect the gastric mucosa

Answer 1

• Bicarb
• blood flow
• prostaglandins
• mucus

Question 2

Name 4 factors that damage the gastric mucosa

Answer 2

• H pylori
• gastric acid
• pepsin
• NSAIDs

Question 3

Name 8 factors that increase gastric acid production

Answer 3

• 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

Question 4

Name the 3 most common sites of benign peptic ulceration

Answer 4

• First part duodenum
• pyloric antrum
• lesser gastric curvature

Question 5

Name the 4 less common sites of benign peptic ulceration

Answer 5

• Distal esophagus
• distal duodenum
• stomach ulcer
• Meckel’s diverticulum

Question 6

Symptoms gastric peptic ulcers? (4)

Answer 6

•Most asymptomatic
• dyspepsia
• postprandial epigastric pain!
• May cause avoidance food → weight loss

Question 7

Symptoms duodenal peptic ulcers? (5)

Answer 7

• Most asymptomatic
• Dyspepsia
• epigastric pain on fasting!
• pain may wake patient up at night, relieved by feeding
• may lead to weight gain

Question 8

Complications peptic ulcers? (5)

Answer 8

• 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)

Question 9

Symptoms perforated peptic ulcer? (2)

Answer 9

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

Question 10

Clinical presentation perforated peptic ulcer ? (8)

Answer 10

• Varying degrees of septic shock
• Tachycardia
• fever
• hypotension
• increased respiratory rate
. Generalised abdominal tenderness
• board like rigidity (peritonitis)
• localised pus collections, rarely pleural abscess

Question 11

Diagnostic investigations perforated peptic ulcer? (5)

Answer 11

• 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

Question 12

Name 4 indications non-surgical management perforated peptic ulcer

Answer 12

• Minimal abdominal signs but clear
• radiographic signs of perforation (rare )
• severe shock with comorbidities
• surgery contraindicated eg elderly with COPD, CCF

Question 13

non-surgical management perforated peptic ulcer?

Answer 13

•
multiple ultrasound guided percutaneous drains
• send pus for MCs
• broad spectrum antibiotics (augmentin) and tailor later

Question 14

surgical management perforated peptic ulcer?

Answer 14

OMental patch (omentopexy) with 6 biopsies, via upper midline laparotomy or laparoscopy
Rinse thoroughly >6 L warm water

Question 15

First line therapy H pylori eradication?

Answer 15

• Ppl
• clarithromycin
• amoxicillin or metronidazole 7-14 days

Question 16

Describe Forrest classification of bleeding peptic ulcer

Answer 16

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

Question 17

Treatment persistently bleeding peptic ulcers? (7)

Answer 17

• 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

Question 18

Definitive treatment gastric outlet obstruction due to peptic ulcer? (7)

Answer 18

• 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