Peptic ulcer disease

Question 1

What are the main causes of peptic ulcer disease?

Answer 1

• Helicobacter Pylori infection (90% duodenal, 70% gastric ulcers)
• NSAIDs (around 30% of ulcers)
• Zollinger-Ellison syndrome (excessive acid secretion due to non-insulin secreting islet cell tumour of pancreas secreting gastrin-like hormone, often leading to excessive ulceration)

Other risk factors: are smoking, coffee cosumption, and hepatic/renal failure

Question 2

How does H. Pylori cause peptic ulceration?

Answer 2

• H. Pylori produces gastritis, mainly in the gastric antrum, leading to activation of an inflammatory infiltrate
• There is also increased acid secretion in the presence of H. Pylori (increased gastrin and decreased somatostatin), and abnormal mucus production, leading to epitheal damage
• H. pylori is also causally associated with duodenal ulcers

Question 3

How does smoking cause peptic ulceration?

Answer 3

• Impairs gastric mucosal healing
• Nicotine increases acid secretion

Question 4

How do NSAIDs cause peptic ulceration?

Answer 4

• NSAIDs inhibit cyclo-oxygenase enzymes, which has anti-inflammatory properties as the COX-2 isoform normally causes inflammatory prostaglandin synthesis
• Adverse GI effects generally occur due to inhibition of COX-1 in the stomach, which is responsible for synthesis of prostaglandins that inhibit acid secretion and protect the mucosa

(given PPIs can diminish gastric damage caused by these agents)

Question 5

What are symptoms of a peptic ulcer?

Answer 5

• Epigastric pain, related to food intake, relieved by antacids
  
  • Pain classically relieved by eating in duodenal ulcers
  • Worse on eating in gastric ulcers
• Nausea
• Anorexia and weight loss
• Haematemesis/melaena ( dark sticky faeces containing partly digested blood)

Question 6

What are the difference between duodenal and gastric ulcers?

Answer 6

Duodenal:

• 4x commoner than gastric ulcers, with 90% within 2cm of the pylorus
• Pain is at night and before meals, relieved by eating food or drinking milk
• Alcohol intake is a risk factor

Gastric:

• occur in older patients (>55), mainly on the lesser curve of the stomach
• Pain is worse on eating, and relieved by antacids

Question 7

How would you investigate peptic ulcer disease?

Answer 7

• Urgent oesophago-gastro-duodenoscopy (OGD) if fir ALARMS55 critieria
  
  • Multiple biopsies taken from rim/base (histology/H. pylori) as well as brushings (cytology)
• No investigation needed if <55, no ALARM symptoms and resolves on antacids
• If symptoms persist on treatment, investigate for H.Pylori (13C urea breath test)