Peptic Ulcer Disease

Question 1

What is Peptic Ulcer Disease?

Answer 1

A Peptic Ulcer is a break in the lining of the GI tract as a result of acid damage to the mucosa, breaking the epithelial lining. Normally Peptic ulcers occur in the first part of the small intestine (a duodenal ulcer) or in the lesser curvature of the stomach (a gastric ulcer)

Question 2

What will you find in a history taking of Peptic Ulcer Disease?

Answer 2

Symptoms:
Epigastric pain - Gastric is relieved by eating, duodenal is worsened by eating and radiates to the back.
It is often nocturnal
Upper GI bleed – Gastric (Haematemesis), Duodenal (Melaena)
Systemic - May see weight loss, Bloating

Risk Factors:
H. Pylori infection
Drugs - NSAIDS, Steroids, Bisphosphonates 
Smoking
Reflux
Stress
Previous history/family history of PUD 
Older Patients – Gastric Ulcers
Younger Patients – Duodenal Ulcers 

Specific Questions to ask:
ALARM – Anaemia, Loss of Weight, Anorexia, Recent onset, Melena/Haematemesis, Swallowing problems, Family Histroy
Differentiate a duodenal ulcer from a peptic one - Gastric Ulcer pain is worse after eating while Duodenal Ulcer pain radiates to the back and is relieved by a meal (but worse 2-5 hours afterwards).
Is the ulcer associated with Diarrhoea – Think Zollinger Ellison
Other Red flags that may make you consider referral – Previous malignancy, family history of upper GI malignancy, Anti Cholinergic drug use, Smoking

Differentials:
Non-Ulcer Dyspepsia – Just simple, diagnosis of exclusion after everything else ruled out
GORD – History of heartburn from the lower chest to throat, associated symptoms – Laryngitis, cough, atypical chest pain
Gastric/Oesophageal Malignancy - ALARM signs, Family history of upper GI cancer, Lymphadenopathy
Gastritis – More frequently associated with vomiting or alcohol. Will see inflammation on endoscopy
Pancreatitis – Epigastric pain radiating to the back, history of alcohol use or gallstones
Biliary Colic – RUQ pain after meals, waning over a few hours. Pain is colicky
Gastroparesis (Delayed gastric emptying due to vagus nerve damage, often as a result of diabetes or peripheral neuropathy) - They get full very quickly

Question 3

What will you find on examination of Peptic Ulcer Disease?

Answer 3

End of the bed:
Shock/Dehydration – Only Assess if the patient has been bleeding
Hands:
Koilonychia - Iron deficiency anaemia
Neck:
Lymphadenopathy – Virchow’s node that may indicate upper GI cancer
Face:
Angular Stomatitis - iron deficiency anaemia
Atrophic glossitis - iron deficiency anaemia
Pale mucous membranes and eyes - Iron deficiency anaemia
Abdomen:
Epigastric Mass – May indicate cancer
Epigastric Tenderness
Legs:
Restless Leg syndrome - Iron deficiency anaemia

Question 4

What investigations will you do in Peptic Ulcer Disease?

Answer 4

Further investigations only required if patient has ALARM symptoms or is >55 required
Bloods:
FBC - looking for anaemia from chronic upper GI bleed
U&E –
Fasting serum gastrin - If Zollinger elision suspected
Amylase – Rule out pancreatitis
Total Iron Binding Capacity/Ferritin - Looking for Iron deficiency due to a chronic bleed

Imaging:
Upper GI endoscopy with biopsies – Only if alarm signs present. Look at ulcer and rule out malignancy, biopsy any irregular looking ulcers as could be cancerous
CXR – Ruling out cardiac cause and looking for any obvious abnormalities

Special:
13C urea breath test or H. Pylori stool antigen testing

Question 5

What is the treatment of Peptic Ulcer Disease?

Answer 5

Lifestyle:
If patient is not indicated for further investigations, then start lifestyle along with first line over the counter antacids. Review in 4 weeks. These include:
Weight Loss
Small meals
Stop smoking
Avoid hot drinks, citrus, spicy food, raise head in bed and avoid eating 3 hours before bed.

Medical:
If no improvement - test for H. Pylori
If positive eradicate and review in 4 weeks - PPI + Amoxicillin and Clarithromycin
If negative Trial a PPI and review in 4 weeks.
If PPI has helped, adjust dose as required
If no improvement, refer for an upper GI endoscopy to confirm peptic ulcer diagnosis
If confirmed, then consider add of medical therapy – H2 Receptor Antagonist

Surgery:
Selective Vagotomy – Can be used last line to reduce acid production if medical treatment failed

Question 6

What are the causes of Peptic Ulcers?

Answer 6

Increased Acid – Diet, Zollinger Ellison

Reduced Protection – NSAIDS, H. Pylori, Bisphosphonates