peptic ulcer disease

Question 1

Which group of patients with H. pylori infection are at risk for peptic ulcer disease

Answer 1

-Antral gastritis

Question 2

How does duodenal peptic ulcer disease present

Answer 2

• 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

Question 3

When is serum gastrin done in the work up for duodenal peptic ulcer disease

Answer 3

• When Zollinger Ellison syndrome is suspected

- Gastrin levels of more than 500 pg/ml and peptic ulcer disease are highly suggestive of the diagnosis

Question 4

Other than peptic ulcer disease, what may cause increased gastrin levels

Answer 4

• Atrophic gastritis associated with achlorydia

- PPI therapy

Question 5

First line treatment for duodenal peptic ulcer disease

Answer 5

• 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

Question 6

Why should patients with gastric ulcers undergo repeat endoscopy

Answer 6

To ensure ulcer healing and to rule out malignancy

Question 7

If a patient is unable to stop NSAID therapy but have developed ulcers, what is their management

Answer 7

maintenance PPI therapy

Question 8

When is surgery indicated for duodenal peptic ulcer disease

Answer 8

Reserved in the main for the complications such as bleeding, perforation, stenosis and, occasionally for persistent penetrating ulcers

Question 9

Clinical presentation of perforation of duodenal peptic ulcers

Answer 9

• 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

Question 10

Special investigations in a perforated peptic ulcer

Answer 10

• 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

Question 11

Treatment of perforated peptic ulcer

Answer 11

• 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

Question 12

When can surgery be left out of management of perforated peptic ulcer

Answer 12

Indicated in patients with localised or sealed perforation and those too ill for surgical intervention

Question 13

End result of duodenal stenosis

Answer 13

• 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

Question 14

Clinical features of duodenal stenosis

Answer 14

• 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

Question 15

Special Investigations in duodenal stenosis

Answer 15

• X-ray abdomen: dilated stomach with food
• ba meal: hold up at the duodenum with a dilated stomach
• endoscopy to exclude carcinoma

Question 16

Treatment of duodenal Stenosis

Answer 16

• 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

Question 17

What are the types of gastric ulcers

Answer 17

• 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

Question 18

Gastric ulcers not occuring in the usual sites should raise the suspicion of ?

Answer 18

-analgesic abuse or gastric carcinoma

Question 19

Clinical presentation of gastric ulcers

Answer 19

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

Question 20

Complications of gastric ulcers

Answer 20

• 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

Question 21

Special investigations for gastric ulcers

Answer 21

• 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

Question 22

Treatment of perforated gastric ulcer

Answer 22

• 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