Peptic Ulcer Disease

Question 1

What does ‘peptic ulcer’ mean?

Answer 1

The term ‘peptic ulcer’ refers to ulcer found in the lower oesophagus, stomach and duodenum
Rarely, they can occur in the jejunum and ileum (usually after surgery).

ulceration of the mucosa of the stomach or proximal duodenum that penetrates to the muscularis mucosa

Question 2

What pathogen are they caused by?

Answer 2

Helicobacter Pylori.

80-90% of duodenal ulcers (DU) and 70% of gastric ulcers are attributed to H. pylori.

Question 3

What is the name given to the inner lining of the GI tract?

Answer 3

Mucosa

Question 4

How does the mucosa protect itself from stomach content?

Answer 4

it secretes mucus that contains bicarbonate that coats the surface and forms a barrier against stomach acid and digestive enzymes

Question 5

Which are more common, gastric or duodenal ulcers?

Answer 5

duodenal ulcers

Question 6

Give 5 risk factors for peptic ulcer disease that increase production of stomach acid:

Answer 6

1) stress
2) alcohol
3) caffeine
4) smoking
5) spicy food

Question 7

Give 2 risk factors for peptic ulcer disease that disrupt the mucus barrier:

Answer 7

1) H. pylori infection
2) NSAID use

Question 8

Give 3 clinical presentations associated with peptic ulcer disease:

Answer 8

1) epigastric discomfort or burning pain (often very localised)
2) nausea and vomitng
3) dyspepsia (indigestion)

Question 9

When is the pain the worst for duodenal ulcer?

Answer 9

When you are hungry

Question 10

When is the pain worse in gastric ulcers?

Answer 10

When you eat

Question 11

Ulcers can bleed - give 4 symptoms of an upper GI bleed:

Answer 11

1) haematemesis (vomiting blood)
2) coffee ground vomiting
3) melaena (black, tarry stools)
4) fall in haemoglobin on full blood count

Question 12

Give 5 drugs that increase the risk of bleeding from a peptic ulcer:

Answer 12

1) NSAIDs
2) aspirin
3) anticoagulants
4) steroids
5) SSRI antidepressants

Question 13

Describe how to distinguish between gastric and duodenal ulcers based on history alone: (2)

Answer 13

1) eating typically worsens the pain of gastric ulcers so patients tend to lose weight due to the fear of pain on eating
2) the pain of duodenal ulcers tends to improve immediately after eating, followed by pain 2-3 hours later, meaning weight is stable or even increases

Question 14

What are 3 non-invasive tests for peptic ulcer disease?

Answer 14

1. Urea breath Test (for presence of H.Pylori)
2. Serological tests for IgG
3. Stool test

Question 15

What invasive investigations are used in peptic ulcer disease?

Answer 15

Endoscopy. (OGD) This will confirm the presence of an ulcer by sight, but a sample of gastric mucosa may also be taken. This can be tested in three ways:

1. Put in a urea solution containing Phenol red. If H. Pylori is present, then the urea will be rapidly split to release ammonia, and the solution will increase in pH and change colour. This is known as the rapid urease test.
2. Cultured and tests against various antibiotics
3. Look at histologically.

FBC – to check for anaemia
U+E – rarely shows up Zollinger-Ellison syndrome
Faecal occult blood
Barium meal test – sometimes used in patients who are unable to tolerate endoscopy.

Question 16

What is the pathology behind H.pylori causing peptic ulcers?

Answer 16

1. H.pylori produces ammonia to neutralise acid around the cell, enabling the cell to survive in the stomach
2. H.pylori tends to live in crypts just next to the acidic sensors of stomach acid, therefore normal feedback mechanisms are altered and excess acid is produced
3. The bacteria causes localised inflammation, and the body’s own stomach acid can worsen the effects of the inflammation

Question 17

When should an endoscopy be performed?

Answer 17

In anyone over 55 or with red flag symptoms.

Question 18

Give 4 management strategies for peptic ulcer disease:

Answer 18

1) stop NSAIDs
2) treat H. pylori infection (amoxicillin and clarithromycin)
3) PPIs (e.g. lansoprazole or omeprazole)
4) stop smoking and drinking alcohol

Question 19

Give an example of the drugs given in triple therapy: (PPI and 2 ABs)

Answer 19

1. Omeprazole
2. Metronidazole
3. Clarithromycin

Question 20

Give 3 complications of peptic ulcer disease:

Answer 20

1. Bleeding
2. Perforation
3. Scarring and strictures

Question 21

How does peptic ulcer perforation present?

Answer 21

acute abdominal pain and peritonitis pain

Question 22

How is a gastric outlet obstruction treated?

Answer 22

Balloon dialation

Question 23

How does gastric outlet obstruction present? (3)

Answer 23

1) early fullness after eating
2) abdominal distention
3) vomiting

Question 24

Describe how scarring and strictures of the stomach can cause gastric outlet obstruction:

Answer 24

scarring and strictures can lead to narrowing of the antrum, causing difficulty in emptying stomach contents