Peptic ulcer disease Flashcards
Describe the epidemiology of peptic and duodenal ulcers.
Onset (gastric): 50-70; M=F
Onset (duodenal): 30-50; M4:1F
Aetiology of peptic ulcers?
-H. pylori (G-ve) (duodenal ulcer)
-NSAIDs (gastric ulcer)
Rarer: ischaemia (stress ulcers in ICU), Zollinger Ellison syndrome, Crohn’s.
What is the broad pathophysiology of gastric ulcers?
Imbalance between damaging and protective factors acting on the gastric mucosa
Which factors damage the gastric mucosa?
Gastric juice, H.pylori, NSAIDs
Which factors defend the gastric mucosa.
Bicarbonate layer, tight junctions between epithelial cells, restitution (rapid migration of cells to fill any damaged area).
Defences depend on adequate blood supply.
Describe the pathophysiology of duodenal ulcers.
Chronic H.pylori infection of the gastric antrum –> impaired SST secretion –> increased gastrin release –> acid hyper secretion.
What is Zollinger Ellison syndrome?
Gastrin secreting neuroendocrine tumour stimulates high gastric acid secretion.
Describe the pathophysiology of H.pylori initiated gastric ulcers.
Longstanding infection throughout the stomach + inflammation –> degrades gastric mucin –> disrupts tight junctions b/w epithelial cells –> induces cell death.
How should PUD be prevented (primary)?
- Judicious NSAID use (consider concurrent PPI Rx)
- ?H.pylori test pre NSAID initiation
Symptoms of gastric ulcer?
- Epigastric pain
- Pain on eating
- Indigestion
Symptoms of duodenal ulcer?
- Epigastric pain
- Pain with hunger (feed ulcer); relieved with food and antacids
- Indigestion
- Periodicity: may remit before recurrence
- Interrupts sleep
- Vomiting due to outflow obstruction resulting from fibrosis
Ix in PUD?
- H.pylori breath test
- Endoscopy (showing ulcer)
- FBC (microcytic anaemia)
- Faecal occult blood
DDx PUD?
- Oesophageal/gastric cancer
- GORD
- Gastroparesis
- Biliary colic
- Pancreatitis
- Coeliac disease
How is uncomplicated PUD managed?
- H.pylori eradication: amoxicillin + metronidazole
- Reduce acid secretion: H2 antagonist (cimetidine, ranitidine) or PPI (omeprazole)
- Stop NSAIDs
- Stop smoking
What are the anatomical considerations in the complications of PUD?
- Posterior wall ulcers penetrate gasproduodenal artery and therefore bleed.
- Anterior wall ulcers perforate into peritoneum
Complications of PUD?
- Penetration into adjacent organ (e.g. pancreas) w/o perforation into peritoneal cavity
- Gastric outlet obstruction (pyloric channel ulcers heal with scarring and oedema)
- Upper GI bleed
- Perforation
Which endoscopic stigmas suggest further ulcer bleeding in PUD?
- actively bleeding vessel
- visible vessels in ulcer base
- adherent clot
- black spot in ulcer base
What are the endoscopic local control methods for ulcers at risk of rebleeding?
- injection of vasoconstrictor (adrenaline in saline)
- thermal coagulation with heater probe
- cold coagulation with cyroprobe
- laser therapy
- clipping of vessel
Describe radiological embolisation in PUD.
Visceral angiography performed via the femoral artery. If bleeding vessel identified, blocked by coils/haemostatic gel.
What is the operative management of a bleeding duodenal ulcer?
Ulcer is expose and bleeding vessel under run with a suture. Large ulcers may required partial gastrectomy.
What is the operative management of a bleeding gastric ulcer?
Limited excision of the stomach or partial gastrectomy (Billiroth I).
Ulcer v erosion?
Ulcer penetrates muscularis mucosa and can produce scarring. Erosion only superficial therefore no scarring.
How is H. pylori eradicated?
Triple therapy for 7 - 14 days: PPI + amoxicillin + clarithromycin
