peptic ulcer disease Flashcards
How does peptic ulcer pain present?
hunger sensation, gnawing dull burning pain. Nausea
Where is the pain in peptic ulcers?
epigastric
What are the three things about the timing of peptic ulcer pain that are important?
- Onset 1-3 hrs after meals
- Awakens from sleep
- Relieved by food/antacid
What percentage of people have silent ulcers?
40%
What percentage of people with ulcer like symptoms only have DYSPEPSIA w/o the ulcer?
60-90%
what are the three complications of peptic ulcers?
hemorrhage
perforation
obstruction
What are the two ways in which peptic ulcer hemorrhages might present?
- POSTERIOR duodenal ulcers erode into major arteries
2. Gastric ulcers can lead to severe/persistent bleeding
What kinds of ulcers likely cause perforation?
anterior DU or GU
What would you see on X ray or CT scan in perforation?
Free air in the peritoneal cavity
What is obstruction?
Scarring and stenosis of the gastric outlet.
What is a prominent feature of peptic ulcer obstruction?
Vomiting, often of old food
Why are the weaknesses of using barium radiograph to diagnose an ulcer?
It can’t tel the difference between a benign ulcer and a gastric cancer that has ulcerated
What is the benefit ofendoscopy?
Can take biopsies to exclude cancer and detect H pylori
What are the methods available for detecting H pylori?
- Histology
- rapid urease test on biopsy
- urea breath test
- Serum antibodies to H pylori (present after eradication of organism)
- Stool antigen test
Where are gastric ulcers usually found?
On the lesser curvature of the stomach
Where are duodenal ulcers found?
In the duodenal bulb
jejunal ulcers are unusual. When might you see them?
In Zollinger Ellison syndrome
ileal ulcers are also unusual. When might you see them?
Merckel’s diverticulum with abnormal gastric mucosa
What are the three ways in which H pylori causes chronic superficial gastritis?
- Stimulating release of IL-1, IL-6, IL-8, and TNF-a
- Gastric metaplasia, causing inflammation/ulceration
- Suppression of somatostatin, causing hypergastrinemia
How does PGE2 maintain mucosal integrity?
- Stimulates mucus production
- Increase mucosal blood flow (ischemia causes back diffusion of H+ ions, hemorrhage, and ulceration
Stimulation of bicarb, and epithelial migration/proliferation
How do NSAIDS decrease PGE2?
Inhibition of cyclo-oxygenase-1–>PGE2
What protects the duodenum from acid?
Brunner’s glands produce mucus with high buffer capacity
Also, biliary and pancreatic secretion have high bicarb
What are other risk factors for peptic ulcer disease?
Cigarette smoking (most important) alcohol coffee psychological factors Nsaids
How does misoprostol work?
It prevents NSAID ulcers. It’s a PGE2 that enhances mucosal production and reduces acid secretion
Sulfated disaccarides
Sucralfate protects damaged mucosa
What are other ulcerogenic drugs?
Indomethacin
What are the side effects of tums?
Hypercalcemia can stimulate acid production, and release of gastrin
What are the side effects of aluminum hydroxide?
constipation, anorexia, weakness, and bond pain
What are the H2 receptor antagonists?
cimetidine, ranitidine, famotidine nizatidine
What are the side effects of cimetidine?
- Mental confusion
- Gynecomastia
- Slows hepatic cytochrome P450 (higher levels of warfarin, diazepam, theophylline, phenytoin)
What are the side effects of ranitidine, famotidine, nizatidine?
DO NOT interfere with cytochrome P450
Less potent anti-androgen effects
When should you give a PPI?
Before the first meal of the day
How do PPIs work?
They accumulate in the secretory canaliculus and block the H/K ATPase.
What are the side effects of PPI?
VERY few! This is why it’s the leading anti-acid. diarrhea and headache sometimes
What cocktail of drugs would you use to eradicate H pylori?
bixmuth, metronidazole, and tetracycline for 2 weeks
What is zollinger-ellison syndrome?
Also known as a gastrinoma, it results in hypersecretion of gastrin, and therefore hypersecretion of acid
What are the clinical features of ZES?
Severe peptic ulcers that are resistant to medical therapy. They have a high frequency of bleeding and perforations. Will also see diarrhea, steatorrhea because acidic gastric secretions increase fluid in gut and absorptive fxns.
Where are ulcers typically found in zollinger ellison?
Duodenum. If found in the jejunum, you KNOW this is ZES!!. Gastric ulcers are less common
What do you need to diagnose ZES?
HIGH gastrin levels, and positive secretin stimulation test if needed
What is the secretin test?
IV secretin normally suppresses gastrin release fro G cells. However, secretin will STIMULATE gastrin release in gastrinomas
What family of genetic disorders do you find ZES?
MEN1
Where are gastrinomas found?
duodenal wall, sometimes in the pancreas. Will often metastasize to the liver
what is the pathophysiology of acute stress ulcerations of stomach?
Linear shallow defects in gastric mucosa. Pts are hyposecretors of acid. But also gastric mucosa breaks down from stress. Seen in ICU patients
What is Cushing’s ulcer?
Patients with intracranial trauma have HIGH acid secretion. Cushing’s ulcer.
