Peptic Ulcer Disease Flashcards
What are the most common cause/s of duodenal and gastric ulcers?
H. pylori infection and/or NSAID use.
What are the causes of duodenal and gastric ulcers?
1 - ZES (gastrinoma). 2 - Antral G-cell hyperfunction and/or hyperplasia. 3 - Systemic mastocytosis. 4 - Trauma. 5 - Burns. 6 - Major physiologic stress. 7 - All NSAIDs. 8 - Aspirin. 9 - Cocaine. 10 - Smoking. 11 - Psychologic stress. 12- H. pylori infection.
How does H. pylori is uniquely equipped for survival in the hostile environment of the stomach ?
By having specialized flagella and a rich supply of urease
What are the causes of chronic gastritis ?
- H. pylori (most common).
- Alcohol.
- NSAIDs.
- Crohn’s disease.
- Tuberculosis.
- Bile reflux (primary or secondary).
What is the most common type of gastric ulcers?
Johnson type I gastric ulcer, is typically located near the angularis incisura on the lesser curvature, close to the border between antral and corpus mucosa.
What is the modified Johnson classification ?
I. Lesser curve, incisura.
II. Body of stomach, incisura + duodenal ulcer (active or healed).
III. Prepyloric.
IV. High on lesser curve, near gastroesophageal junction.
V. Medication-induced (NSAID/ acetylsalicylic acid), anywhere in stoma
What are the risks of chronic use of NSAIDs (including aspirin) ?
increases the risk of:
- Peptic ulcer disease about 5-fold.
- Upper GI bleeding about 4-fold.
What are the factors that clearly put patients at increased risk for NSAID-induced GI complications and the need of having acid suppressing medication?
- Age over 60
- History of acid/peptic disease
- Concurrent steroid intake
- Concurrent anticoagulant intake
- High-dose NSAID or acetylsalicylic acid
How does smoking is associated with PUD?
- Increases gastric acid secretion and duodenogastric reflux.
- Decreases both gastroduodenal prostaglandin production and pancreaticoduodenal bicarbonate production.
What are the symptoms and signs of PUD?
- Nonradiating pain, burning in quality, and located in the epigastrium. - Nausea. - Bloating. - Weight loss. - Stool positive for occult blood. - Anemia - Dyspepsia
What are the Alarm symptoms that indicate the need for upper endoscopy ?
- Weight loss
- Recurrent vomiting
- Dysphagia
- Bleeding
- Anemia
What are the Indications for diagnosis and treatment of Helicobacter pylori ?
Established
- Active peptic ulcer disease (gastric or duodenal ulcer)
- Confirmed history of peptic ulcer disease (not previously treated for H. pylori)
- Gastric mucosa-associated lymphoid tissue lymphoma (low grade).
- After endoscopic resection of early gastric cancer
- Uninvestigated dyspepsia (depending on H. pylori prevalence).
Controversial
- Nonulcer dyspepsia
- Gastroesophageal reflux disease
- Persons using NSAIDs
- Unexplained iron deficiency anemia
- Populations at higher risk for gastric cancer
What are the most common complications of PUD?
- Bleeding.
- Perforation.
- Obstruction.
What are the two widely used risk stratification tools in predicting rebleeding and death in bleeding PUD?
- Blatchford Score.
- Rockall Score.
What are the most common endoscopic hemostatic modalities used in bleeding PUD ?
- Injection with epinephrine.
- Electrocautery
What is the initial management of perforated peptic ulcer?
- History: patient can give exact time of onset of the
excruciating abdominal pain. - On Ex: obvious distress, peritoneal signs. Usually, marked involuntary guarding and rebound
tenderness. - Radiology: Upright CXR shows free air in about 80% of patients.
- Initial Mx: analgesia and antibiotics, resuscitated with isotonic fluid, and taken to the operating room.
What is the clinical manifestation of Gastric outlet obstruction?
- Nonbilious vomiting.
- Profound hypokalemic hypochloremic metabolic alkalosis.
- Pain or discomfort is common.
- Weight loss
What is the initial treatment of gastric obstruction ?
- Nasogastric suction.
- IV hydration.
- Electrolyte repletion and cid suppression.
How to confirm Dx of gastric obstruction ?
Diagnosis is confirmed by endoscopy
What is the medical Treatment of peptic Ulcer Disease ?
- PPIs are the mainstay of medical therapy.
- High dose of H2RAs and sucralfate are also effective.
- Stop smoking.
- Avoid alcohol and NSAIDs (including aspirin).
What are the initial regimens of treating Helicobacter pylori?
- PPI + clarithromycin 500 mg bid + amoxicillin 1000 mg BID for 10–14 d.
- PPI + clarithromycin 500 bid + metronidazole 500 bid for 10–14 d.
- PPI + amoxicillin 1000 mg bid for 5 d , then
PPI + clarithromycin 500 mg bid + Tinidazole 500 mg bid for 5 d.
What are the Salvage regimens for patients who fail one of the initial regimens treating H.pylori ?
- Bismuth subsalicylate 525 mg qid + metronidazole 250 mg qid + tetracycline 500 mg qid + PPI for 10-14 d.
- PPI + amoxicillin 1000 mg bid + levofloxacin 500 mg daily for 10 days.
What are the indications for surgery in PUD in general ?
- Bleeding.
- Perforation.
- Obstruction.
- Intractability or nonhealing.
What are the basic operations for peptic ulcers
treatment ?
- Parietal cell vagotomy (highly selective vagotomy HSV ) (proximal gastric vagotomy).
- Vagotomy and drainage (V+D).
- vVgotomy and distal gastrectomy.
