Peptic Ulcer Disease

Question 1

List the main causes of peptic ulcers?

Answer 1

Main causes:
H.Pylori (duodenal more commonly)
NSAIDs

Rare:
Zollinger-Ellison Syndrome (gastrin secreting tumours)

Smoking is a risk factor

Question 2

What are the differences between duodenal and gastric ulcers including in presentation?

Answer 2

Location.

H.pylori more commonly causes duodenal ulcers

Symptoms of pain usually occur shortly after food in gastric ulcers and several hours after food in duodenal ulcers. Pain may improve after eating in duodenal ulcers.

Weight loss more common in gastric ulcers as they eat less due to the pain.

Depending on the location of the duodenal ulcer there may be pain radiating to the back.

Question 3

List the clinical signs and symptoms of peptic ulcers?

Answer 3

Epigastric pain:

• a few hours after food.
• may radiate to the back in posterior duodenal ulcers.
• pain may wake the patient up at night.
• relieved by food (particularly duodenal ulcers) and antacids.

Other sx:
Nausea
Bloating and distension
Heartburn

Complications:
Anaemia due to bleeding
Perforation ——–> peritonitis

Question 4

Describe how H.pylori causes peptic ulcers?

Answer 4

H.Pylori is a bacteria that is responsible for the majority of peptic ulcers roughly 90% of duodenal and 70% of gastric.

Proteins released by H.Pylori lead to a decreased production of somatostain by D cells and a decrease in the inhibition of gastrin by G cells.

Somatostatin usually leads to reduce acid secretion.

The extra gastrin stimulates extra secretion of acid by parietal cells.

Furthermore H.Pylori leads to a decreased secretion of bicarbonate.

The combination of these factors lead to a net increase of acid and therefore causes ulceration.

Question 5

Describe how NSAIDs and smoking can cause peptic ulceration?

Answer 5

NSAIDS are Cox inhibotors and inhibit COX 2 (important in the pain response) as well as COX 1 receptors in the stomach which synthesise protective prostoglandins.

Prostaglandins are normally involved in decreasing acid secretion and promoting bicarbonate and mucus secretion (protection).

Smoking impairs mucosal healing.

Question 6

Describe how peptic ulcer disease is managed?

Answer 6

Initiation of a PPI (should take ~4weeks to heal)

Test for H.pylori

Question 7

Describe how H.pylori is investigated?

Answer 7

C13 urease breath test
Stool antigen test
CLO test at endoscopy (campylobacter like organism)
Biopsy

Endoscopy should be performed in patients that have not responded to treatment or have any red flag symptoms.

Note: if a ulcer is found on endoscopy it should be biopsied and a repeat endoscopy should be performed after treatment has commenced.

Question 8

What are the red flag symptoms in the upper GI tract?

Answer 8

New onset dyspepsia after the age of 55.

Dysphagia
Weight loss
Epigastric mass
Persistent vomiting
Iron deficiency anaemia 
Haematemesis/melaena
FH/PMH of GI carcinoma

Question 9

Describe the treatment regimen of H.pylori?

Answer 9

Triple therapy

PPI* + Clarithromycin 500mg bd +

Amoxocillin 1g bd OR Metronidazole 400mg bd

• Lansoprazole, Omeprazole etc

Question 10

What is a longer term complication of H.pylori infection?

Answer 10

H.pylori is associated with:

• Gastric cancer
• MALT Lymphoma

Question 11

What are the complications of peptic ulcer disease?

Answer 11

Perforation: need an emergency laparotomy and abx

Bleeding: haematemesis/melaena

Gastric outlet obstruction due to strictures

Question 12

What are the main causes of haematemesis?

Answer 12

Oesophageal varices

Peptic ulcer

Question 13

Describe the management of haematemesis?

Answer 13

Resus

Endoscopy:

• local adrenaline injection +
• clips OR banding

OR

Angioembolistaion by intervention radiologists

Start prophylactic abx as likely that aspiration has occurred.

If due to a varice use Telepressin (vasopressor) also