Peptic ulcer disease Flashcards
What is peptic ulcer disease?
- A break in the mucosal lining of the stomach or duodenum more than 5mm in diameter, with depth to the submucosa.
- Ulcers smaller than this or without obvious depth are called erosions
Causes of peptic ulcer disease
Two major aetiologic factors:
-Infection by gram-negative H.pylori (survives in acidic conditions)
-Use of aspirin and NSAIDs
Rarer causes include:
-Gastric ischaemia (stress ulcers)
-Hypersecretory syndromes which increase the production of stomach acid. These are rare but you may have heard of the Zollinger-Ellison syndrome.
-Certain medications (potassium chloride, bisphosphonates)
-Crohn’s disease
Pathophysiology of peptic ulcer disease
Peptic ulcer result from an imbalance between factors promoting mucosal damage (gastric acid, pepsin, H.pylori and NSAIDs) and those mechanisms promoting gastroduodenal defence (prostaglandins, mucus, bicarbonate, mucosal blood flow).
Role of H.pylori in peptic ulcer disease
Gastric ulcers (70%) Duodenal ulcers (80-95%) -H.pylori burrows through the protective mucosa which lines the stomach, with a preference for the antrum. -There's a destructive impact on 'D' cells within the stomach which dampen down acid production in the stomach, therefore an overall impact of increasing acid production and lowering pH of the stomach juices
How do you test for infection with H.pylori?
Urea breath test
Stool antigen test
A blood test to look for antibodies
Role of NSAIDs in peptic ulcer disease
NSAIDs inhibit COX-1 (decreased blood flow) and COX-2 (neutrophil adherence) and also causes topical irritation (epithelial damage).
Decreased blood flow, neutrophil adherence and epithelial damage leads to mucosal injury
What are the types of peptic ulcer disease?
Gastric ulcers.
Duodenal ulcers.
Signs and symptoms of peptic ulcer disease
- Abdominal pain
- ‘pointing sign’ - the patient can show site of pain with one finger
- Epigastric tenderness
- Nausea or vomiting
- Early satiety
- Diarrhoea
Risk factors of peptic ulcer disease
H.pylori infection NSAIDs Smoking Increasing age Personal Hx of peptic ulcer disease Family Hx of peptic ulcer disease Patient in intensive care Physical stress e.g major trauma/surgery
Investigations of peptic ulcer disease
H.pylori- urea breath test or stool antigen test
Upper GI endoscopy
FBC
Differentials of peptic ulcer disease
Oesophageal cancer Stomach cancer GORD Gastroparesis Biliary colic Acute pancreatitis Non-ulcer dyspepsia Coeliac disease IBS Pleuritic pain Pericarditis
Management of peptic ulcer disease
Active bleeding ulcer:
-Endoscopy w/without blood transfusion
-PPI (omeprazole 80mg IV bolus)
-Surgery or embolisation via IV radiology
No active bleeding: H.pylori negative-
-Treat underlying cause plus PPI
- H2 antagonist if PPI is CI
No active bleeding: H.pylori positive :
-Triple therapy (Clarithromycin 500mg BD),
Amoxicillin ( 1000mg BD), PPI (omeprazole 20-40mg OD)
-If there’s an allergy to penicillin, metronidazole is given rather than the amoxicillin
Complications of peptic ulcer disease
-Penetration- into an adjacent organ like the pancreas
-Upper GI bleeding- signs of bleeding include haematemesis, melaena and haemorrhagic shock (if bleed severe)- bleeding can cause an iron deficiency anaemia
-Perforation:
Fluids and air escape into the peritoneal cavity
Acute abdomen and peritonitis
Emergency surgery needed
-Gastric outlet obstruction:
Epigastric abdominal pain and postprandial vomiting due to obstruction
Malignancy is now the predominant cause rather than peptic ulcers
Most common is pancreatic cancer extending into the duodenum and gastric outlet followed by primary gastric cancer
Important information about gastric cancer
Gastric cancers are relatively uncommon
They usually present with symptoms similar to peptic ulcer disease or gastric outlet obstruction
They are most often picked up on endoscopic examination of gastro-intestinal tract and biopsies of ulcers or other abnormal-looking tissues.
Risk factors for developing gastric cancers are chronic gastritis and there is an association with H. Pylori infection.
Which medications are linked with the formation of peptic ulcers or GI bleeds?
SSRIs (Selective Serotonin Reuptake Inhibitors).
Corticosteroids.
Anticoagulants.
Non-steroidal anti-inflammatory drugs (NSAIDs).
Antiplatelets.
Potassium Channel Activators – Nicorandil