Peptic ulcer disease

Question 1

Define peptic ulcers

Answer 1

Break in the superficial epithelial lining of either stomach (gastric) or duodenum (more common)

Break = >5mm in diameter with depth to submucosa
Erosions = <5mm

Question 2

Aetiology of peptic ulcer disease

Answer 2

H. Pylori
NSAIDs
Zollinger-Ellison syndrome (gastrin-secreting neuro-endocrine tumour →↑ gastric acid)
ICU stays (>48hr ventilation) / gastric ischaemia→ stress ulcers
Bisphosphonates, aspirin, steroids, KCl
Infection - CMV in HIV patients, TB
Crohn’s disease
Cushing’s ulcers (brain trauma), Curling’s ulcers (burns), altered gastric emptying
Sarcoidosis

Question 3

Risk factors for peptic ulcer disease

Answer 3

H. Pylori
NSAIDs
Family history
Increasing age
Smoking
Alcohol
Psychological stress

Question 4

Symptoms and signs of peptic ulcer disease

Answer 4

Dyspepsia (indigestion/heartburn)
Abdominal pain: after eating, nocturnal, relieved by antacids
Nausea and vomiting
Early satiety
Anorexia and weight loss or weight gain
“Pointing sign” - can pinpoint where the pain is

Gastric: pain immediately after eating, 50-70yo
Duodenal: pain 3 hours after eating, 40-60yo

Question 5

Features of Zollinger-Ellison syndrome

Answer 5

Abdominal pain
Diarrhoea
Multiple recurrent duodenal ulcers

Associated with MEN

Question 6

Features of peptic ulcer rupture

Answer 6

Sudden onset pain
Melaena
Coffee-ground vomit

Question 7

Referral pathway for dyspepsia

Answer 7

Urgent (2ww) OGD:
- Dysphagia
- Upper abdominal mass
- >55 AND weight loss AND dyspepsia/reflux/GORD/upper abdo pain
- >60 with NEW onset dyspepsia

non-urgent OGD:
>55yo AND
- Treatment-resistant dyspepsia
- Upper abdo pain + anaemia
- N&V + reflux/weight loss/ dyspepsia upper abdo pain
- Raised platelets + N&V/weight loss/reflux/dyspepsia/upper abdo pain

Question 8

Investigations for peptic ulcer disease

Answer 8

Stool antigen test (must not be on PPIs)
H. pylori urea breath test (must not be on PPIs)
ECG

Serology
FBC
U&Es
LFTs
CRP
Amylase
Fasting serum gastrin level: ?zollinger-Ellison syndrome

Erect CXR: ?perforation
AXR
OGD + Biopsy: Ulcerating or exophytic mucosal lesions that may narrow the lumen

Question 9

Management for peptic ulcers

Answer 9

Lifestyle management i.e. avoid spicy food, alcohol, late meals, big meals, stop smoking
Review medications

“Trial” full dose PPI 4-8W OR H. pylori treatment

Trial: PPI or H2RA + ranitidine

H. pylori
Triple therapy:
1. PPI e.g. omeprazole 20mg
2. Amoxicillin
3. Clarithromycin/metronidazole

Re-test with breath test if no resolution
Unsuccessful → repeat with another antibiotic

Ulcer identified on endoscopy: eradication therapy + 4-8 PPI/H2RA

Non-healed: exclude malignancy, Crohn’s, Zollinger-Ellisons, GIST

Question 10

Complications of peptic ulcer disease

Answer 10

Pancreatitis
Haematemesis
SOB and syncope
Massive GI bleed, shock and syncope
- Ulcer erodes into wall of blood vessel
Peritonitis
- From perforation of the ulcer eroding through the wall o the stomach or duodenum into peritoneal cavity
Pyloric stenosis/gastric outlet obstruction
- Ulcer → inflammation/scarring → blocked outflow → stomach full of gastric acid juice + food → vomiting without pain
Malignancy
MALToma
Atrophic gastritis
Gastric cancer

Question 11

Prognosis of peptic ulcer disease

Answer 11

With PPI:
- Duodenal ulcers typically heal within 4 week
- Gastric ulcers typically heal within 8 weeks
Risk of recurrence (H. pylori) - duodenal 20%, gastric 30%
Discontinuation NSAID - low rate ulcer recurrence
Continuing NSAID use increases rate of ulcer recurrence
UGI bleeds carry 7% mortality, rising to 26% inpatients