Peptic ulcer disease

Question 1

what is it?

Answer 1

Ulceration of areas of the GI tract caused by exposure to gastric acid and pepsin.

Peptic ulcers are most commonly gastric and duodenal (but they can also occur in the oesophagus and Meckel’s diverticulum).

Question 2

commonest causes of pud and gastritis?

Answer 2

There is a strong correlation with Helicobacter pylori

COMMON CAUSES of peptic ulcer disease and gastritis:

Helicobacter pylori
NSAIDs

Question 3

what is Zollinger-Ellison syndrome ?

Answer 3

a condition in which a gastrin-secreting tumour or hyperplasia of the islet cells in the pancreas cause overproduction of gastric acid, resulting in recurrent peptic ulcers

Question 4

Presenting symptoms of pud and gastritis?

Answer 4

Epigastric pain

Relieved by antacids

Symptoms have a variable relationship to food intake:

Gastric - pain is worse soon after eating

Duodenal - pain is worse several hours after eating

Patients may present with complications e.g. haematemesis, melaena

Question 5

signs?

Answer 5

may be none

maybe epigastric tenderness
anaemia possibly

Question 6

ivx?

Answer 6

1. FBC (for anaemia)
2. Serum amylase (to exclude pancreatitis)
3. Upper GI endoscopy
4. Testing for H. pylori; breath or stool
5. Biopsy
   Biopsies of gastric ulcers can be taken to rule out malignancy
   Duodenal ulcers do NOT need to be biopsied

others;
Serum gastrin test - (if Zollinger-Ellison syndrome suspected) - IV secretin causes a rise in serum gastrin in ZE patients but not in normal patients)

Question 7

What are the 4 different tests for h. pylori?

Answer 7

1. H.pylori breath test
   C13-urea breath test :
   Radio-labelled urea is given by mouth
   C13 is detected in the expelled air
2. Stool antigen
3. Serology:
   IgG antibody against H. pylori confirms exposure to H. pylori but NOT eradication
4. Campylobacter-like organism (CLO) test:
   Gastric biopsy is placed with a substrate of urea and a pH indicator
   If H. pylori is present, ammonia is produced from the urea and there is a colour change from yellow to red

Question 8

What is the rockall scoring system?

Answer 8

Scores the severity after a GI bleed

Score < 3 carries good prognosis

Score > 8 carries high risk of mortality

Question 9

Management plan if there is active bleeding?

Answer 9

Acute bleeding;

1. Endoscopy + blood transfusion
   - endoscopy used to guide cautery or clip the site.
   - adrenaline injectedt to site to stop bleed
   - discontinue nsaids

1a. + PPI ; Omeprazole

2nd line. Surgery; for perforated ulcers or if endoscopic therapy fails.

Question 10

Management plan if there is no active bleeding, and h.pylori negative?

Answer 10

1st line ; PPI - omeprazole

Question 11

Management plan if there is no active bleeding, and h.pylori positive?

Answer 11

H.pyllori eradication;

a combination of 2 antibiotics + PPI

Omeprazole + Clarithromycin + Amoxicillin (triple therapy for 1-2 weeks)

if pen allergic: Metronidazole + Clarithromycin

Question 12

Management plan if the patient has frequently recurrent ulcers?

Answer 12

omeprazole (acid suppression therapy)

Question 13

Management plan if ulcer is associated with nsaid use and not respinding to omeprazole?

Answer 13

misoprostol