Peptic Ulcer Disease

Question 1

What are the common causes of Peptic Ulcer Disease?

Answer 1

H. Pylori infection (90% duodenal, 70% gastric)
NSAIDs (30% ulcers)
Zollinger-Ellison Syndrome
Smoking/coffee consumption, hepatic/renal failure)

Question 2

What is Zollinger-Ellison syndrome?

Answer 2

Excessive acid secretion due to gastrin secreting islet cell tumour

Question 3

What are the presenting sx of Peptic Ulcer Disease?

Answer 3

Eigastric pain (related to food intake, relieved by antacids)
   -Duodenal (pain relieved by eating)
   -Gastric (pain worse on eating)
Nausea
Anorexia/Wt loss
Haematemesis/Malaena

Question 4

What investigations are appropriate in suspected Peptic Ulcer Disease?

Answer 4

None needed if <55/no ALARM sx/resolves on GORD rx
Urgent OGD (if ALARMS 55 criteria met)
H. pylori ix

Question 5

What investigations can be used to confirm an infection w/ H. Pylori?

Answer 5

13C Urea Breath Test
Gastric biopsies (colour change w/ phenol red urea solution)

Question 6

Describe the 13C Urea Breath Test

Answer 6

Pt ingests 13C labelled urea
If H. Pylori present urease enzyme produces 13CO2
This can be detected on the breath

Question 7

What are the key distinguishing features of duodenal ulcers?

Answer 7

4x more common than gastric ulcers
90% w/i 2cm of pylorus
Pain at night/before meals, relieved by food/milk
Alcohol intake as risk factor

Question 8

What are the key distinguishing features of gastric ulcers?

Answer 8

Older pts (>55)
On lesser curve of stomach
Pain worse on eating, relieved by antacids

Question 9

What are the pathological consequences of H. Pylori infection on PUD?

Answer 9

Gastritis (mainly in antrum) causing inflammatory infiltrate
Increased acid secretion & abnormal mucus production –> epithelial damage
Can cause atrophic gastritis –> metaplasia

Question 10

What are the pathological consequences of smoking on PUD?

Answer 10

Impairs gastric mucosal healing

Nicotine increases acid secretion

Question 11

What are the pathological consequences of NSAIDs on PUD?

Answer 11

NSAIDs inhibit COX enzymes (anti-inflammatory)
-adverse GI effects due to COX-1 inhibition
Steroids also have this effect

Question 12

How can the pathological consequences of NSAIDs on PUD be avoided?

Answer 12

Co-administration of PPIs/PG analogues

Question 13

What are the management options for PUD, if ALARMS 55 sx not present?

Answer 13

Lifestyle measures (avoid food that worsens sx, stop smoking)
Medications - PPIs/H2RAs, stop NSAIDs

Question 14

What are the management options for PUD, if H. Pylori is present?

Answer 14

Triple therapy

• PPI + 2/ab for 7/7
• Omeprazole/Clarithromycin/Amoxicillin
• Metronidazole (if penicillin allergic)

Question 15

What are the management options for PUD, if resistant?

Answer 15

Bismuth Chelate w/ 2 a/b for 14/7

Prolonged PPI therapy

Question 16

What surgical options exist for managing PUD?

Answer 16

Highly selective vagotomy
Vagotomy & pyloroplasty
Gastrectomy
Complication management

Question 17

When is surgical management for PUD used?

Answer 17

Pts who cannot tolerate medical therapy

Gastrectomy in Zollinger-Ellison

Question 18

What are the features of a highly selective vagotomy?

Answer 18

Vagus nerve severed to reduce acid production

Nerve of Latarget intact so gastric emptying unaffected

Question 19

What are the features of a vagotomy & pyloroplasty?

Answer 19

Full vagotomy reduces acid production but affects gastric emptying
Pyloroplasty required to allow gastric emptying