Peptic ulcer disease

Question 1

Describe the epidemiology of peptic and duodenal ulcers.

Answer 1

Onset (gastric): 50-70; M=F

Onset (duodenal): 30-50; M4:1F

Question 2

Aetiology of peptic ulcers?

Answer 2

-H. pylori (G-ve) (duodenal ulcer)
-NSAIDs (gastric ulcer)
Rarer: ischaemia (stress ulcers in ICU), Zollinger Ellison syndrome, Crohn’s.

Question 3

What is the broad pathophysiology of gastric ulcers?

Answer 3

Imbalance between damaging and protective factors acting on the gastric mucosa

Question 4

Which factors damage the gastric mucosa?

Answer 4

Gastric juice, H.pylori, NSAIDs

Question 5

Which factors defend the gastric mucosa.

Answer 5

Bicarbonate layer, tight junctions between epithelial cells, restitution (rapid migration of cells to fill any damaged area).
Defences depend on adequate blood supply.

Question 6

Describe the pathophysiology of duodenal ulcers.

Answer 6

Chronic H.pylori infection of the gastric antrum –> impaired SST secretion –> increased gastrin release –> acid hyper secretion.

Question 7

What is Zollinger Ellison syndrome?

Answer 7

Gastrin secreting neuroendocrine tumour stimulates high gastric acid secretion.

Question 8

Describe the pathophysiology of H.pylori initiated gastric ulcers.

Answer 8

Longstanding infection throughout the stomach + inflammation –> degrades gastric mucin –> disrupts tight junctions b/w epithelial cells –> induces cell death.

Question 9

How should PUD be prevented (primary)?

Answer 9

• Judicious NSAID use (consider concurrent PPI Rx)

- ?H.pylori test pre NSAID initiation

Question 10

Symptoms of gastric ulcer?

Answer 10

• Epigastric pain
• Pain on eating
• Indigestion

Question 11

Symptoms of duodenal ulcer?

Answer 11

• 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

Question 12

Ix in PUD?

Answer 12

• H.pylori breath test
• Endoscopy (showing ulcer)
• FBC (microcytic anaemia)
• Faecal occult blood

Question 13

DDx PUD?

Answer 13

• Oesophageal/gastric cancer
• GORD
• Gastroparesis
• Biliary colic
• Pancreatitis
• Coeliac disease

Question 14

How is uncomplicated PUD managed?

Answer 14

• H.pylori eradication: amoxicillin + metronidazole
• Reduce acid secretion: H2 antagonist (cimetidine, ranitidine) or PPI (omeprazole)
• Stop NSAIDs
• Stop smoking

Question 15

What are the anatomical considerations in the complications of PUD?

Answer 15

• Posterior wall ulcers penetrate gasproduodenal artery and therefore bleed.
• Anterior wall ulcers perforate into peritoneum

Question 16

Complications of PUD?

Answer 16

• 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

Question 17

Which endoscopic stigmas suggest further ulcer bleeding in PUD?

Answer 17

• actively bleeding vessel
• visible vessels in ulcer base
• adherent clot
• black spot in ulcer base

Question 18

What are the endoscopic local control methods for ulcers at risk of rebleeding?

Answer 18

• injection of vasoconstrictor (adrenaline in saline)
• thermal coagulation with heater probe
• cold coagulation with cyroprobe
• laser therapy
• clipping of vessel

Question 19

Describe radiological embolisation in PUD.

Answer 19

Visceral angiography performed via the femoral artery. If bleeding vessel identified, blocked by coils/haemostatic gel.

Question 20

What is the operative management of a bleeding duodenal ulcer?

Answer 20

Ulcer is expose and bleeding vessel under run with a suture. Large ulcers may required partial gastrectomy.

Question 21

What is the operative management of a bleeding gastric ulcer?

Answer 21

Limited excision of the stomach or partial gastrectomy (Billiroth I).

Question 22

Ulcer v erosion?

Answer 22

Ulcer penetrates muscularis mucosa and can produce scarring. Erosion only superficial therefore no scarring.

Question 23

How is H. pylori eradicated?

Answer 23

Triple therapy for 7 - 14 days: PPI + amoxicillin + clarithromycin