Peptic ulcer disease Flashcards
What is a peptic ulcer?
- Break in the lining of the GIT, extends to the muscular layer
- Endoscopic diagnosis
- Duodenal (4x more common)
- Majorty first part of duodenum on anterior wall
- Gastric
- Mostly distal half of lesser curvature
Causes of peptic ulcer disease?
- Imbalance between acid-pepsin system and mucosal ability to resist digestion
- H. pylori
- NSAIDs
- Prostaglandins responsible for producing mucus and bicarbonate
- NSAIDs inhibt action of cyclo-oxygenase in prostaglandin synthesis
Name some things that protect the gastrointestinal mucosa under normal circumstances?
- Surface mucous secretion
- Bircarbonate release
How can you differentiate between gastric and duodenal ulcers from a clinical history?
- Duodenal
- More common
- Epigastric pain, relieved by eating
- Gastric
- Epigastric pain, worse with eating
Describe H. pylori?
- Gram negative spiral-shaped bacillus
- Survives stomach by producing alkaline micro-environment
- Induce inflammatory response which leads to ulceration
How does H pylori induce inflammatory ulceration in the stomach?
- Drives inflammatory response
- Causes gastic acid hypersecretion
- Damages host mucosa by direct colonisation
Risk factors for peptic ulcer disease?
- H. pylori infection
- Prolonged NSAID use
- Corticosteroid use
- Previous gastric bypass
- Physiological stress
- Severe burns
- Head trauma
- Zollinger-Ellison syndrome
Clinical features of peptic ulcer disease?
- Asymptomatic (70%)
- Epigastric or retrosternal pain
- Nausea, bloating, early satiety
When should patients by referred for an urgent upper oesophageal0gastro-duodenoscopy (OGD)?
- New onset dysphagia
- Aged >55years with weight loss + upper abdo pain, reflux or dyspepsia
- New onset dyspepsia not responding to PPI treatment
Diffferentials for peptic ulcer disease?
- Acute coronary syndrome
- GORD
- Gallstones
- Gastric malignancy
- Pancreatitis
Describe Zollinger Ellison syndrome?
- Triad of:
- Severe peptic ulcer disease
- Gastric acid hypersecretion
- Gastrinoma
- Characteristic finding of gastrin >1000pg/ml
- 1/3 of cases are part of MEN type 1 syndrome
Describe MEN1?
Pancreas / pituitary / parathyroid tumours
Investigations into a suspected peptic ulcer disease?
- FBC
- Non-invasive H. pylori testing
- Carbon-13 urea breath test
- Serum antibodies to H. pylori
- Stool antigen test
- OGD for older patients/red flags/ongoing symptoms
- Biopsy of ulcer sent for histology and rapid urease test
What is important to remember about testing for H. pylori?
Patients should stop any current medical therapy 2 weeks prior to invesitgation to reduce the risk of false negatives
Describe the management of peptic ulcer disease?
- Lifestyle advice (smoking, weight loss, alcohol consumption, avoid NSAIDs)
- PPI for 4-8 weeks to reduce acid production
- After this they are reassessed for resolution of symptoms
- Patients with positive H. pylori should receive triple therapy
- PPI + oral amoxicillin and clarithromycin for 7 days
- Surgical (usually only for perforation or Zollinger Ellison syndrome
- Severe or relapsing disease the following can be considered:
- Partial gastrectomy
- Selective vagotomy
