Peptic ulcer disease Flashcards
Causes of peptic ulcers?
H. pylori
NSAIDs
Blood Group O have increased HCl production
Acid hypersecreters
Zollinger-Ellison syndrome –> gastrinoma
Clinical features of duodenal peptic ulcer?
Epigastric pain relieved by eating, for ~2 hours
Nocturnal pain
Anorexia, vomiting, weight loss –> delayed gastric emptying
Natural history of peptic ulcer disease?
Relapsing and remitting pattern
Special investigations for peptic ulcer disease?
Endoscopy with biopsy x 4 quadrants
Breath urease for H. pylori (not necessarily needed)
Serum gastrin when suspecting Z-E syndrome (>500pg/ml is highly suspicious)
Barium meal - done uncommonly nowadays
What is the empiric medical therapy of PUD?
PPI for 2 weeks
Abx for 1 week to eradicate H. pylori: amoxicillin 1g BD + metronidazole 400mg BD/clarithromycin 500mg BD
Stop NSAID use if using
What are the complications of PUD?
SHOP:
- Stenosis [3]
- Haemorrhage (haematemesis, melaena, coffee grounds) [1]
- Obstruction [4]
- Perforation [2]
What is the pathophysiology of duodenal stenosis following PUD?
- Large penetrating ulcers with associated inflammation and oedema
- Healed ulcer with fibrosis
Clinical presentation of gastric ulcers?
Pain related to eating –> patient often afraid to eat
Vomiting –> dehydration
Epigastric pain radiating to the back
What hormone do G cells produce?
Gastrin
What hormone do D cells produce?
Somatostatin
What do parietal cells produc?
HCl
Intrinsic factor
What do Chief cells produce?
Pepsiongen
What are protective factors against PUD?
Mucus layer
HCO3
Prostaglandin E2: augments mucus and HCO3, as well as increasing mucosal blood flow
Mechanism of NSAIDs causing PUD?
Non-selective COX inhibitors:
- COX-2 inhibition reduces inflammation, pain in rest of body –> this is fine
- COX-1 inhibition inhibits PGE2 production –> this is a problem (see other card)
Do posterior duodenal ulcers bleed or perforate more, and why?
They bleed, because the gastroduodenal artery runs posterior to D1
Do anterior duodenal ulcers bleed or perforate more? What investigation shows this?
They perforate
Free air under the diaphragm
What is the endoscopic/surgical management of a bleeding peptic ulcer?
- Gold probe coagulation + adrenalin/H20 tamponade + high dose PPI
- 2nd bleed: repeat scope
- 3rd bleed: surgery + H. pylori eradication therapy
What is the surgical management of a perforated peptic ulcer?
Laparotomy + omental patch repair + PPI + Abx
Clinical signs of gastric outlet obstruction?
Projectile vomiting
Succussion splash
Hypokalaemic hypochloraemic metabolic alkalosis
What is the incisura angularis on the lesser curvature of the stomach?
The area of transition from parietal to G/D cells in the stomach
Johnson classification of gastric ulcers: Class I
On the lesser curvature, within 2cm of incisura on pyloric side
Most common
Johnson classification of gastric ulcers: Class II
Class I + a duodenal ulcer
Associated with high HCl output
Johnson classification of gastric ulcers: Class III
Within 3cm of pyloris (pre-pyloric), anywhere
Associated with high HCl output
Johnson classification of gastric ulcers: Class IV
High on the lesser curvature
(the higher the ulcer on the lesser curve, the more extensive the chronic gastritis)
Due to relative parietal cell loss, tend to have less HCl production
