peptic ulcer disease Flashcards
Which group of patients with H. pylori infection are at risk for peptic ulcer disease
-Antral gastritis
How does duodenal peptic ulcer disease present
- Upper abdominal pain related to meals, often relieved by food, and coming on again half an hour to two hours after meals
- Nocturnal pain
- Persistent pain or pain radiating to the back is suggestive
- Associated heartburn is common, especially with delayed gastric
- Anorexia, vomiting and weight loss point to delayed gastric emptying
- Untreated: relapsing and remitting pattern
- patients go into remission for varying periods which can be weeks, months, seasonal or for many years
When is serum gastrin done in the work up for duodenal peptic ulcer disease
- When Zollinger Ellison syndrome is suspected
- Gastrin levels of more than 500 pg/ml and peptic ulcer disease are highly suggestive of the diagnosis
Other than peptic ulcer disease, what may cause increased gastrin levels
- Atrophic gastritis associated with achlorydia
- PPI therapy
First line treatment for duodenal peptic ulcer disease
- PPI for two weeks
- One week antibiotic course (consisting of amoxicillin and metronidazole or clarithromycin
- Patients with gastric ulcers and NSAIDs induced ulcers should take PPIs for a month in addition to eradication therapy
Why should patients with gastric ulcers undergo repeat endoscopy
To ensure ulcer healing and to rule out malignancy
If a patient is unable to stop NSAID therapy but have developed ulcers, what is their management
maintenance PPI therapy
When is surgery indicated for duodenal peptic ulcer disease
Reserved in the main for the complications such as bleeding, perforation, stenosis and, occasionally for persistent penetrating ulcers
Clinical presentation of perforation of duodenal peptic ulcers
- Dyspepsia
- Onset is acute in majority of cases: Epigastric pain increasing in severity over a 24- 48 hour period, patient can recall the exact time it occurred. Patient is acutely distressed with initial neurogenic shock. Hypovolemia and severe metabolic derangement are seen in delayed cases
- Abdo exam: Board like rigidity with absent bowel sounds . Gross distension occurs later on
Special investigations in a perforated peptic ulcer
- Erect CXR and AXR will show air under the diaphragm in 80%
- Serum amylase may be raised
- Gastrografin swallow indicated in doubtful cases or when conservative therapy is considered
- Endoscopy is contra indicated
Treatment of perforated peptic ulcer
- Resusciation
- Analgesics for neurogenic shock
- Nasogastric tube
- Hypovolemia resuscitation
- Broad spectrum antibiotics
- Surgery: Primary closure with an omental patch followed by HP eradication if tested postively
When can surgery be left out of management of perforated peptic ulcer
Indicated in patients with localised or sealed perforation and those too ill for surgical intervention
End result of duodenal stenosis
- severe dehydration
- raised urea and haematocrit
- Low serum chloride, sodium and potassium
- Serum alkalosis an intra cellular acidosis
- Decrease in serum ionized calcium which result in tetany
- urine is alkalotic and in advanced cases acidotic
Clinical features of duodenal stenosis
- history of dyspepsia and loss of weight
- anorexia nausea and vomiting of undigested food- non bile stained usually
- metabolic and nutritional derangements
- on examination: dehydration, upper abdominal distension, visible peristalsis, succession splash
Special Investigations in duodenal stenosis
- X-ray abdomen: dilated stomach with food
- ba meal: hold up at the duodenum with a dilated stomach
- endoscopy to exclude carcinoma
Treatment of duodenal Stenosis
- rehydration with normal saline and correction of potassium deficit
- hyperalimentation or enteral feeding via feeding tube placed beyond the Stenosis
- stomach washouts with wide bore tube
- peptic ulcer therapy
- endoscopic dilatation
- surgery: usually entails pyloroplasty
What are the types of gastric ulcers
- Pre pyloric (<2cm from the pylorus)
- Combination of duodenal and gastric ulcer
- Ulcers > 2cm from the pylorus on the lesser curve, usually above the angulus
Gastric ulcers not occuring in the usual sites should raise the suspicion of ?
-analgesic abuse or gastric carcinoma
Clinical presentation of gastric ulcers
Dyspepsia: Pain precipitated by meals occurs more commonly than duodenal ulcers. Patients are afraid to eat
- Weight loss is not uncommon especially when associated with anorexia, nausea and vomiting
- Epigastric fullness, mild cramps and belching may also form part of the symptom complex
Complications of gastric ulcers
- Bleeding
- Perforation: into the peritoneal cavity/ into the lesser sac/ sealed off by the liver
- Penetration into the pancreas
- Gastric outlet obstruction is seen more commonly with pre pyloric ulcers
Special investigations for gastric ulcers
- Barium meal: typically an ulcer crater on the lesser curve of the stomach or an ulcer crater without irregular raised margins and thickened folds
- Endoscopy with four quadrant biopsies should be routinely performed to exclude carcinoma
- tests for HP should also be done
Treatment of perforated gastric ulcer
- Primary closure and biopsy is preferred when the perforation is small or in the presence of longstanding perforation with excessive contamination
- For large ulcers and those where malignancy is suspected: Standard Bilroth I gastrectomy is recommended
