Peptic Ulcer Disease

Question 1

What is it?

Which type of ulcer is more common?

Answer 1

Erosions of gastric mucosa or duodenal mucosa which extends into the submucosa or deeper.

Duodenal ulcer 4x than gastric ulcer

Question 2

Cause is imbalance of harmful factors and protective factors.

List the harmful factors

List the protective factors

Answer 2

Acid
Pepsin

Mucus bicarbonate layer
Prostaglandins
Epithelial tight junctions

Question 3

What is DU’s associated?

How does H.pylori cause a DU?

Answer 3

Gastric acid hypersecretion

Due to H.pylori in gastric antrum
Lower somatostatin release
Increased gastric release
Increased acid secretion

Question 4

GU’s are associated with normal or low acid.

How do NSAID’s lead to GU’s?

How does H.pylori lead to GU’s?

Answer 4

Lower prostaglandins
Lower mucin production
Less bicarbonate production

Inflammation and damage to epithelial tight junctions

Question 5

Causes

• 2 main causes
• Medication used to treat inflammation - NOT NSAID’s
• Lifestyle
• Asked in history - 2

Answer 5

H.pylori - cause 80% of all ulcers
NSAID’s - cause 20% of all ulcers

Steroids

Enhanced gastrin and parietal cell hyperplasia with increased acid secretion, diminished gastric mucus synthesis, and suppressed arachidonic acid metabolism and prostaglandin (PG) synthesis

Alcohol
Smoking

FH
Stress

Question 6

S+S:

What does epigastric pain shortly after food suggest?

What does epigastric pain 2-3 hours after food suggest?

What type of ulcer is likely to wake you up at night?

Where might pain radiate to in a DU?

What does pain relief by eating suggest?

Answer 6

Gastric ulcer

DU

Of course - the food reaches the gastric ulcer before a duodenal ulcer

DU

Back

DU - because the acid in the digestive tract doesn’t have a buffer without food - you don’t have the protective factor - so eating buffers the acid, relieving pain - hence the point of PPI’s

Question 7

S+S:

2 other main symptoms?

Symptoms of complications:

What 2 things could you find if there was a bleeding ulcer?

What would vomiting whole food suggest?

Answer 7

Nausea

Epigastric tenderness

Haematemesis
Melena (bleeding ulcer)

Gastric outlet obstruction

Question 8

Investigations:

2 ways to test for H.pylori at GP?

What needs to stopped before doing these tests and for how long?

Why do you do FBC?

Answer 8

13C urea breath test
Stool antigen test

Pylori produces an enzyme called urease, which breaks urea down into ammonia and carbon dioxide. During the test, a tablet containing urea is swallowed and the amount of exhaled carbon dioxide is measured. This indicates the presence of H. pylori in the stomach.

PPI

2 wks

Iron deficiency anaemia

Question 9

Investigations:

A 2WW for endoscopy is necessary if alarming signs of gastric cancer or oesophageal cancer are present. List a few

Answer 9

>55 yrs old at onset (and persistent)
Persistent vomiting 
Dysphagia 
Weight loss 
Upper GI bleeding (or iron deficiency anaemia)
Epigastric mass

Question 10

Investigations - endoscopy

Why is a biopsy done? - one for cancer and one for H.pylori

What needs to stopped before doing these tests and for how long?

Answer 10

Histology for cancer - cannot tell an ulcer and cancer apart 
CLO test (aka rapid urease test - can only be done with a biopsy) - H.Pylori 

PPI

2 wks

Question 11

Ulcer prevention in high risk patients:

What should be given to patients on long term steroids?

NSAID’s should be avoided in these patients. What alternative can be considered?

Answer 11

Prophylactic PPI’s

COX2 inhibitor (celecoxib) over other NSAIDS + PPI

Question 12

Management of dyspepsia:

What should be reviewed?

What lifestyle changes can be made?

When should an endoscopy be done?

How do you know if it is more likely to be PUD than GORD?

Answer 12

Medications - NSAIDS

Smoking and alcohol - stop for a month

Alarm signs

Epigastric pain predominates

Question 13

H.pylori:

If test positive, what triple therapy is given?

What if test is negative?

Answer 13

7 days of PPI - can keep for months 
\+ 
1 wk of Amoxicillin
\+ 
1 wk of Clarithromycin or Metronidazole

1-2 months of PPI (omeprazole or lansoprazole)

Question 14

Ulcer surgery

Indications - 4

Early complications - 2

Answer 14

Ulcer unresponsive to medical treatment
Bleeding ulcer
Perforated ulcer
Gastric outlet obstruction

Bleeding
Bilious vomiting

Question 15

Ulcer surgery

Late complications - dumping syndrome, diarrhoea, anaemia, osteomalacia

What id dumping syndrome and what does it cause?

Answer 15

Rapid food entry into the small bowel

Fluid shifts into bowel and reactive hypoglycaemia

Question 16

Complications of PUD:

2 main ones

Why do you get gastric outlet obstruction

Answer 16

Upper GI bleed
Perforation or penetration (gastrocolic fistula)

Pyloric stenosis is caused by scarring and oedema of pyloric ulcers

Question 17

Perforated peptic ulcer:

S+S:

Where does the pain start and then move to?

Systemic sign

What is likely to happen with blood in the abdominal cavity?

Answer 17

Epigastric then generalised

Shock

Peritonitis

Question 18

Perforated peptic ulcer:

What should you see on an erect CXR?

What other imaging can be used?

Answer 18

Pneumoperitoneum

Abdo CT

Question 19

Perforated peptic ulcer:

‘Drip and suck’ is the initial management. What does it mean?

What can be used to relieve symptoms and prevent infection? - 2

What 2 things need to be done to repair the ulcer?

Answer 19

IV fluids
NG tube to empty stomach contents

PPI
Antibiotics

Peritoneal washout and surgical repair with patch of omentum

Question 20

Gastritis:

What is it?

What is it a precursor for?

Risk factors and causes?

Answer 20

Inflammation of the gastric mucosa

Ulcers

Same as PUD

So gastritis is a precursor of a gastric ulcer (PUD)

Question 21

Gastritis:

S+S

How is it diagnosed?

Treatment - 2

Answer 21

Epigastric pain
N&V
Upper GI bleeding

Endoscopy with biopsy

Symptomatic relief - Anti-acid medications and H.pylori eradications