Peptic ulcer disease

Question 1

What is the definition and epidemiology of peptic ulcer disease (7)

Answer 1

1. Peptic Ulcer Disease (PUD): localised loss of mucous protection in stomach or duodenum leading to acidic/enzymatic irritation, inflammation, erosion, bleeding and ulceration.
2. Confirmed by endoscopy
3. Life time prevalence 5-10%
4. Most pass with few or no symptoms
5. 0.3% incidence of symptomatic ulcers
6. Gastric prevalence - peaks between 45-64 y/o, affects men 2x more than women
7. Duodenal prevalence - increases with age, equal between men and women

Question 2

what are the causes of peptic ulcer disease (6)

Answer 2

1. Most common: H. Pylori infection (95% duodenal and 70-80% gastric)
2. Next most common: Drug related
3. NSAIDs increase ulcer complications x4
4. Aspirin doubles ulcer complications
5. Other risk factors: smoking, alcohol (maybe stress)
6. Rare: Zollinger-Ellison syndrome

Question 3

what are other implicated drugs causing peptic ulcer disease (5)

Answer 3

1. bisphosphonates
2. corticosteroids
3. potassium supplements
4. selective serotonin reuptake inhibitors (SSRIs)
5. recreational drugs such as crack cocaine.

Question 4

What abundance of damaging factors cause peptic ulcer disease (8)

Answer 4

1. H pylori
2. Damaging drugs
3. Pepsin
4. Bile reflux
5. Gastric acid
6. Slow gastric emptying
7. Lifestyle
8. PG deficiency

Question 5

What lack of protective factors cause peptic ulcer disease (6)

Answer 5

1. Mucus
2. Bicarbonate
3. Prostaglandins
4. Mucosal renewal
5. Protective drugs
6. Mucosa blood flow

Question 6

what are the common signs of gastric and duodenal ulcers (5)

Answer 6

1. Epigastric pain: mild to severe or “burning” or “gnawing”
2. Waking at night with pain
3. Periodic, recurrent symptoms, with symptom-free intervals reducing if there is no treatment
4. Nausea and/or vomiting (blood → ALARMS)
5. Often asymptomatic until severe complications arise

Question 7

What are the signs of gastric ulcers (6)

Answer 7

1. Symptoms follow a less consistent pattern
2. Eating can exacerbate symptoms
3. Gastric cancer concern
4. Male
5. over 45
6. family history

Question 8

what are the signs of duodenal ulcers (3)

Answer 8

1. Typically a more consistent pain
2. Pain can wake you at night
3. Relieved by food- returning 2-3 hours later

Question 9

What are the alarm symptoms of ulcers (6)

Answer 9

1. Anaemia
2. Loss of weight
3. Anorexia (not eating)
4. Recent onset of progressive symptoms
5. Melaena (black, tarry stool) or heamatemesis (vomiting blood)
6. Swallowing issues

Question 10

what are the complications of peptic ulcer disease (4)

Answer 10

1. Heamorrhage - may be life-threatening, case fatality rate of 5–10%, and chronic bleeding may cause iron deficiency anaemia.
2. Perforation - may cause peritonitis which may be life-threatening, mortality rate of up to 20%.
3. Gastric outlet obstruction - from strictures and stenosis of thepylorus and/or duodenum due to chronic inflammation and scarring.
4. Gastric malignancy - an increased risk inHelicobacterpyloripositive gastric ulcer disease. Biopsies of gastric ulcers always taken because of this

Question 11

what are the peptic ulcer disease lifestyle measures (9)

Answer 11

1. Reduce damage to stomach
2. Review/stop: NSAIDs, aspirin, bisphosphonates, steroids, potissium, SSRI’s, discuss illicit drug taking of crack cocaine.
3. If high risk with NSAIDs: Change to COX-2 selective
4. Weight loss (if obese)
5. Avoid trigger foods (Fatty, spicy)
6. Smaller meals, eating evening meal 3-4 before bed
7. Smoking cessation
8. Reduce alcohol
9. Measures to reduce stress and anxiety

Question 12

how is helicobacter pylori detected (5)

Answer 12

1. A number of ways. All require 2 weeks with no PPI and 4 weeks no Abx
2. Campylobacter Like Organism (CLO) test: biopsy at endoscopy
3. Serology: measures antibodies to organism in plasma
4. Faecal antigen testing: H pylori antigens in stool samplem - More accurate: 90-100% sensitivity
5. Labelled C-urea breath test: >95% sensitivity, 14C cheap but radioactive, 13C detection expensive (not radioactive)

Question 13

how is H. pylori eradicated for patients with no penicillin allergy (4)

Answer 13

1. 1st line: 7 days PPI + amoxicillin + clarithromycin or metronidazole
2. 2nd : metro. (whichever not tried already) 7 days PPI + amoxicillin + clari .or
3. Unlicensed 2nd if patient has had calri. and metro.:7 days PPI + amox. + tetracycline (or levofloxacin if tetracycline cannot be used)
4. SPECIALIST 3rd line: 10 days PPI + bismuth (u/l) + any 2 Abx from above or rifabutin (u/l) or furazolidone (u/l)

Question 14

how is H. pylori eradicated for patients with a penicillin allergy (5)

Answer 14

1. 1st line: 7 days PPI + clarithromycin + metronidazole
2. Alternate 1st previously had clari.: 7 days
   PPI + bismuth (u/l) + metronidazole + tetracycline (u/l)
3. 2nd line having not had fluoroquinolone: 7 days PPI + metronidazole + levofloxacin (u/l)
4. 2nd line have had fluoroquinolone): 7 days
   PPI + bismuth (u/l) + metronidazole + tetracycline
5. SPECIALIST 3rd line: 10 days PPI + bismuth (u/l) + rifabutin (u/l) or furazolidone (u/l)

Question 15

What is the H.pylori cancer risk (10)

Answer 15

1. Group 1 carcinogen (known carginogen)
2. CagA gene → immunodominant antigen on H. pylori
3. 20 fold risk of gastric cancer
4. Over 90% of patients with gastric B lymphomas have H. pylori
5. Low grade tumours have been shown to regress with H. pylori eradication
6. Group 1: carcinogenic
7. Group 2A: probably carcinogenic
8. Group 2B: possibly carcinogenic
9. Group 3: not classifiable
10. Group 4: probably not carcinogenic