Peptic Ulcer Disease

Question 1

What is a peptic ulcer

Answer 1

Break in the lining of the GI tract extending through to the muscular mucosa of the bowel

Question 2

Where do ulcers most commonly occur?

Answer 2

Lesser curvature of the proximal stomach and wrist part of the duodenum

Question 3

Describe the protective factors of the GI mucosa

Answer 3

Surface mucous secretion

HCO3- release

Question 4

Describe when ulceration occurs

Answer 4

Overwhelmic presence of noxious substance or when natural barriers are impaired

Question 5

What are the most common causes of PUD? Others?

Answer 5

Helicobacter pylori
NSAIDs

High alcohol intake
Steroid use
Foreign body ingestion - battteries

Question 6

How do NSAIDs cause PUD?

Answer 6

Inhibit prostaglandin synthesis
This results in a reduced secretion of glycoprotein, mucous and phospholipids by the gastric epithelial cells, which would otherwise normally contribute to the barrier protecting the gastric mucosa.

Question 7

What kind of organism is H. pylori? How does it survive in the stomach?

Answer 7

Gram negative (blue) spill shaped bacillus
Survives in the stomach by producing an alkaline micro-environemnet and induces an inflammatory response in the mucosa leading to eventual ulceration

Question 8

How does H. pylori cause ulceration?

Answer 8

Invoking cytokine and interleukin driven inflammatory response in the mucosa
Increasing gastric acid secretion in the acute and chronic phases of infection, increasing the release of histamine which acts on parietal cells
Damaging the host mucus secretion by degrading the surface glycoproteins and down regulating bicarb production.

Question 9

What are risk factors for PUD?

Answer 9

H. pylori infection
Prolonged NSAID use

Smoking, alcohol excess, chemotherapy, radiotherapy’s steroid use

Question 10

How do gastric ulcers present?

Answer 10

Epigastric pain - exacerbated by eating
Nausea and anorexia
Weight loss

Question 11

How do duodenal ulcers present??

Answer 11

Epigastric pain worse around 2-5 hours after eating

Worse when fasting and can be alleviated by eating

Question 12

What symptoms suggest an urgent OGD to assess for malignancy?

Answer 12

ALARMS
Anaemia
Lost weight
Recent onset/progressive
Melena/haemetemesis
Swallowing difficulties

OR

New onset dysphagia
Aged >55 with weight loss and either upper abdominal pain, reflux or dyspepsia
New onset dyspepsia not responding to PPI

Question 13

What are important differentials for epigastric pain?

Answer 13

Gastric malignancy, pancreatitis, ACS, GORD, gallstones

Question 14

What is Zollinger Ellison syndrome?

Answer 14

Severe PUD
Gastric acid hyper secretion
Gastrinoma

Raised fasting gastrin level

Question 15

What investigations for PUD?

Answer 15

Upper GI endoscopy - OGD
Allows for biopsy for histology and rapid urease test for H. pylori

FBC to assess for anaemia

For those who do not require upper GI endoscopy, Non-invasive H. pylori testing: serum antibody, stool antigen, carbon 13 urea breath test

Question 16

What advice would you give to a PUD patient?

Answer 16

Smoking cessation
Weight loss
Reduction in alcohol consumption
Avoid NSAIDs where possible - stop drugs causing dyspepsia

Question 17

If patients are H pylori negative and fail conservative management, what next?

Answer 17

Start PPI (omeprazole, lansoprazole) for 8 weeks to reduce acid production.

Question 18

How do you treat H. pylori positive patients?

Answer 18

TRiple therapy
PPI
ORal amoxicillin 
\+ clarithromycin or metronidazole
7 days

Question 19

What would you think if there is persistent symptoms post PPI therapy? How would you check

Answer 19

MAlignancy
Failure of H pylori eradication - urea breath test
Zollinger Ellison
Consider Upper GI endoscopy

Question 20

What are complications of PUD?

Answer 20

Bleeding, perforation, malignancy, reduced gastric outflow due to pyloric stenosis

Question 21

Differentials for dyspepsia?

Answer 21

DU/GU
OESophagitis/GORD
Duodentitis
Malignancy
Gastritis

Question 22

Key age risk factor?

Answer 22

55 or over