Peptic Ulcer Disease

Question 1

What are the two main causes of peptic ulcers?

Answer 1

H.Pylori, NSAIDs (smoking too a much lesser extent)

Question 2

Which gender is more likely to develop a peptic ulcer?

Answer 2

Males (especially older ones)

Question 3

What percentage of cases of gastric and duodenal ulcers are a result of H.Pylori respectively?

Answer 3

70% of gastric (rest NSAIDs)

90% of duodenal (rest smoking)

Question 4

How does H.Pylori cause ulceration in duodenum?

Answer 4

Forms ammonia from urea via urease raising the pH of the local area causing inhibition of somatostatin and hypergastrinaemia and increased acid secretion which damages duodenal mucosa

Question 5

How does H.Pylori cause ulceration in the stomach?

Answer 5

Reduces the ability of the gastric mucosa to protect itself from acid and pepsin

Question 6

How do NSAIDs cause ulceration?

Answer 6

The cox-1 pathway in traditional NSAIDs is inhibited and this prevents proper formation of mucous and bicarbonate secretion

Question 7

What symptoms do duodenal and gastric ulcers have in common?

Answer 7

Epigastric discomfort, dyspepsia, temporary relief upon taking antacids

Chronic ulceration: weight loss, anorexia, anaemia

Question 8

What must be excluded?

Answer 8

Malignancy

Question 9

Symptoms of gastric vs duodenal

Answer 9

Pain increased by eating vs pain relieved by eating
Pain occurs between 30-60mins vs 2-3 hours
Less common vs more common
Vomiting occurs vs melena occurs

Question 10

Investigations for duodenal include?

Answer 10

Do endoscopy and H.Pylori testing

Question 11

How is H.Pylori testing done?

Answer 11

Breath test (highly sensitive and specific) required withholding PPIs 4 weeks previously

Serology (IgG good for differentiating current/past infections)

Biopsy

Question 12

What tests are done for gastric ulcers?

Answer 12

Upper GI endoscopy to exclude malignancy and do H.Pylori testing

Question 13

Management?

Answer 13

Stop NSAIDs, lifestyle changes,

If H.pylori negative? PPI inhibitors, H2 blockers
If positive? Eradicate

Question 14

How is H.Pylori treated?

Answer 14

Triple therapy 
2 times daily
Full dose PPI
Amoxicillin 1g
Clarithromycin 500mg

Question 15

Differentials for dyspepsia?

Answer 15

GORD, oesophagitis, non-ulcer dyspepsia, gastric malignancy, peptic ulcer, gastritis, duodenitis

Question 16

What are the ALARM Signs for malignancy?

Answer 16

Anaemia, Loss of weight, Anorexia, Recent onset/progression, Melaena/haematemesis, Swallowing difficulty

Question 17

Repeat endoscopy is done at 6 months to check healing as what complications can occur in peptic ulcer disease?

Answer 17

Bleeding and perforation

Question 18

How is bleeding treated?

Answer 18

Fluid resus, acid suppression, inject ulcers with adrenaline, heat probe coagulation or clip placement.

If this all fails surgery will be required

Question 19

What are the signs and treatment of perforation?

Answer 19

Abdo tenderness, guarding, rebound tenderness, erect CXR shows air under diaphragm

Give broad spectrum antibiotics and emergency surgery required

Question 20

What is a peptic ulcer?

Answer 20

A break in the mucosa of the lower oesophagus, stomach or duodenum. Can be acute or chronic

Question 21

If the peptic ulcer is particularly treatment resistant what must you consider?

Answer 21

Zollinger-Ellison syndrome (a rare adenoma that secretes gastrin causing peptic ulcers)

Question 22

What surgery might be done for peptic ulcers?

Answer 22

Highly selective vagotomy (removes parasympathetic stimulation, reducing gastric acid secretion)