Peptic Ulcer Disease

Question 1

Peptic Ulcer Disease: What is it?

Answer 1

Peptic Ulcer Disease= ulceration of the mucosa of the stomach (gastric ulcer) or the proximal duodenum (duodenal ulcer), which is more common. Peptic ulcers can bleed into the upper GI (most common complication).

Question 1

Peptic Ulcer Disease: Risk Factors

Answer 1

Factors that disrupt the mucus barrier or increase stomach acid:

Risk factors that disrupt the mucus barrier are:
- Helicobacter pylori
- Non-steroidal anti-inflammatory drugs (NSAIDs)
- SSRIs, corticosteriods, bisphosphonates

Risk factors that increase stomach acid are:
- Stress
- Smoking
- Alcohol
- Caffeine
- Spicy foods
- Zollinger-Ellison syndrome: rare cause characterised by excessive levels of gastrin, usually from a gastrin secreting tumour

The risk of bleeding from a peptic ulcer is increased with the use of:
- Non-steroidal anti-inflammatory drugs (NSAIDs)
- Aspirin
- Anticoagulants (e.g., DOACs)
- Steroids
- SSRI antidepressants

Question 2

Peptic Ulcer disease: Investigations

Answer 2

• FBC
• endoscopy with biopsy to exclude malignancy
• H-pylori testing (urea breath test or stool antigen test) - first line

Question 3

Peptic ulcer disease: Management

Answer 3

The core aspects of treating peptic ulcers are:
Stopping NSAIDs
Treating H. pylori infections with triple therapy - if h-pylori positive
Proton pump inhibitors (e.g., lansoprazole or omeprazole) - if hpylori negative

Repeat endoscopy (at 4-8 weeks) may be performed to ensure the ulcer heals.

Management for acute bleed
ABC approach as with any upper gastrointestinal haemorrhage
IV proton pump inhibitor
the first-line treatment is endoscopic intervention
if this fails (approximately 10% of patients) then either:
urgent interventional angiography with transarterial embolization or
surgery

Question 4

Peptic Ulcer Disease: Complications

Answer 4

Bleeding from the ulcer is a common and potentially life-threatening complication.

Perforation results in acute abdominal pain and peritonitis, requiring urgent surgical repair (usually laparoscopic).

Scarring and strictures can lead to a narrowing of the exit of the stomach, causing difficulty in emptying the stomach contents. This is known as gastric outlet obstruction and presents with early fullness after eating as well as upper abdominal discomfort, abdominal distention and vomiting, particularly after eating. This may be treated with balloon dilatation during an endoscopy or surgery.

Question 5

Peptic Ulcer Disease: Symptoms

Answer 5

epigastric pain
nausea + vomiting
dyspepsia
duodenal ulcers - epigastric pain when hungry, relieved by eating
gastric ulcers - epigastric pain worsened by eating

The signs of upper gastrointestinal bleeding are:
Haematemesis (vomiting blood)
Coffee ground vomiting
Melaena (black, tarry stools)
Fall in haemoglobin on a full blood count

Question 6

Peptic Ulcer Disease:
Perforation

Answer 6

The symptoms of perforation secondary to peptic ulcer disease typically develop suddenly:
* epigastric pain, later becoming more generalised
* patients may describe syncope

Investigations
* An upright (‘erect’) chest x-ray is usually required when a patient presents with acute upper abdominal pain can show free air under the diaphragm