Peptic Ulcer Disease

Question 1

What can PUDs be caused by?

Answer 1

H pylori, NSAIDs, stress
(others: Zollinger-Ellison syndrome, granulomatous disease, hyperCa, Crohn’s, other infections)

Question 1

What are the two types of PUDs?

Answer 1

Gastric ulcer and duodenal ulcer

Question 2

Difference in epigastric pain of duodenal and gastric ulcer?

Answer 2

Duodenal: worse at night, may be relieved by eating, occurs 1-3h after meal
Gastric: worse by eating

Question 3

What enzymes in H pylori allow it to thrive in the stomach?

Answer 3

• Urease: converts urea to ammonia -> neutralise gastric acid
• Catalase: kills phagocytes -> resulting inflammation damages gastric epithelial lining

Question 4

How is H pylori spread?

Answer 4

Orally: vomit, diarrhoea

Question 5

Diagnosis method?

Answer 5

Non-invasive: urea breath test, stool antigen test
Invasive: endoscopy (histology)

Test for both diagnosis and eradication

Question 6

What should patients do to reduce false negative results from tests?

Answer 6

• Discontinue anti-secretory agents (e.g. PPI) or abx at least 2 weeks before the test OR
• Wait 4 weeks after tx has ended before testing

Question 7

What can cause false negative results in testing?

Answer 7

Bismuth, abx, PPI, H2RA

Question 8

Common symptoms of PUD

Answer 8

Epigastric pain (esp night), heartburn, belching, bloating, N/V, anorexia (7)

Question 9

Complications of PUD

Answer 9

Bleeding, obstruction, perforation (3)

Question 10

1st line for PUD? And duration

Answer 10

Triple therapy
- Clarithromycin 500mg BD
- Amoxicillin 1g BD / Metronidazole 500mg TDS
- PPI BD
- 14D

Question 11

Salvage therapies for PUD?

Answer 11

Bismuth Quadruple
- Bismuth subsalicylate 300 or 525mg QDS or bismuth substrate 120-300mg QDS
- metronidazole 250mg QDS or 500mg TDS-QDS
- tetracycline 500mg QDS
- PPI BD
- 10-14D

Levofloxacin Triple
- Levofloxacin 500mg OD
- Amoxicillin 1g BD
- PPI BD
- 10-14D

Question 12

What is considered low, moderate and high GI risk?

Answer 12

Low: no risk factors
Moderate: >65y, high dose NSAID therapy, hx of uncomplicated ulcer, concurrent use of aspirin/corticosteroids/anticoagulants
High: hx of complicated ulcer, >2 risk factors

Question 13

What is used to treat NSAID-induced PUD?

Answer 13

PPI, misoprostol

Question 14

Treatment algorithm for pts with CVD but require pain management

Answer 14

1. Topical NSAIDs
2. Paracetamol, aspirin, tramadol, short-term narcotics
3. Nonacetylated salicylates (salsalate, choline magnesium trisalicylate)
4. Non-selective COX NSAIDs
5. NSAIDs with some COX-2 activity
6. Celecoxib