Peptic Ulcer Disease

Question 1

What is peptic ulcer disease?

Answer 1

Focal ulceration of stomach or duodenal tissue

Question 2

Pain tends to occur ____ eating. Compare gastric and duodenal ulcer pain timing.

Answer 2

After -
In gastric ulcers pain usually occurs briefly after eating because acid is secreted and irritates the ulceration. “the pain gets worse when I eat.”

Duodenal ulcers tend to occur few hours after eating and is relieved by eating immediately as bicarbonate is released when food is still in stomach. “my pain gets better when I eat”

Question 3

Causes of PUD

Answer 3

Majority: NSAIDs and H. pylori
Other:
- Cushing's ulcer from head trauma
- Curling's ulcer following burns
- Mechanical ventilation
-Crohn's disease
- ZES (Zollinger Ellison Syndrome)

Question 4

Redflag Sx in GIT

Answer 4

• Weight loss
• Anaemia
• Haematemesis
• Malaena
• Early satiety
• Dyspahgia
• Older than age 45

Question 5

How should we test for H. pylori?

Answer 5

a. Serology (Ab to H. pylori): most sensitive - any exposure leads to Ab formation, but not necessarily current infection
b. Gastric biopsy: most specific, but requires endoscopy
c. Stool antigen: checks for present infection, good to use if pt response to therapy without doing biopsy

Question 6

What is the best first step in the management of a pt with suspected PUD (with no alarm sx)?

Answer 6

H. pylori serology

Question 7

What is the most accurate test for H. pylori infection?

Answer 7

Gastric biopsy

Question 8

Clinical features of PUD

Answer 8

• Post-prandial epigastric pain
• Epigastric pain that awakens pt at night
• Dyspepsia that does not respond to antacids
• Alarm Sx (before)

Question 9

Dx of PUD

Answer 9

Pts w/o alarm sx should be tested for H pylori with serology

Pts w/ alarm sx should receive endoscopy (active bleeding should get scoped right away)

Question 10

What if the pt does not respond to treatment in the case of a non- H. pylori ulcer (e.g. NSAID)?

Answer 10

After 6-8 weeks, if no improvement of sx then pt should get endoscopy and biospy of the ulcer (is it cancer?)

Question 11

Do alcohol and tobacco cause ulcers?

Answer 11

NO they delay healing

Question 12

List the complications of PUD

Answer 12

a. Perforated ulcer
b. Bleeding -> haematemesis, maleana
c. Obstruction - pyloric stenosis
d. Anaemia (blood loss)
e. Cancer in GU
f. Oesophageal stenosis

Question 13

DUs are more common in __?

Answer 13

Men

Question 14

DU: GU ratio?

Answer 14

4:1

Question 15

Risk factors of PUD

Answer 15

• Male
• FHx
• Smoking (delay healing)
• Stress
• Common in blood group O
• NSAIDs 2-4 times increase in GU and ulcer complications
• H pylori

Question 16

What are the different types of PUD?

Answer 16

• Lower oesophageal
• Gastric
• Stomal (post gastric surgery)
• Duodenal

Question 17

Ix of PUD

Answer 17

1. Endoscopy (investigation of choice): 92% of predictive value
2. Barium studies
3. Serum gastrin
4. H pylori test: serology or urea breath test; diagnosis is usually based on urease test performed at endoscopy

Question 18

Management of PUD

Answer 18

Conservative:

• Same principles as for GORD
• Stop smoking
• Avoid irritant drugs: NSAID
• Normal diet but avoid foods that upset
• Antacids

Pharmacological:
- PPIs of 4-8 week oral course (more potent acid suppression than H2 receptor antagonists)

Other: 
- Cytoprotective agents: sucralfate 
- Prostaglandin analogue: misoprostol
- Coloidal bismuth subcitrate
-

Question 19

Therapy to eradicate H. pylori

Answer 19

First line:
1. PPI + 2. Clarithromycin + 3. Amoxicillin
All orally for 7 days

Question 20

If H pylori is resistant or no improvement after 2 weeks:

Answer 20

After 2 weeks, if there is NO improvement
bismuth + PPI + tetracycline + metranidazole
(Quadruple therapy)

Question 21

Prevention of ulcers in NSAID user

Answer 21

Primary prophylaxis resrved for sig increased risk e.g. > 75 years, past Hx of PU:
- PPI use

Question 22

Prevention of ulcers in NSAID user

Answer 22

Primary