Peptic Ulcer Disease

Question 1

What is peptic ulcer disease?

Answer 1

Break in the epithelial lining of the stomach/duodenum

gastric or duodenal ulcer

Question 2

Symptoms of peptic ulcer disease?

Answer 2

Recurrent epigastric pain relating to eating
Early satiety
Nausea and vomiting
Potential anorexia/weight loss

Question 3

Types of peptic ulcer disease?

Answer 3

Gastric ulcer

Duodenal ulcer

Question 4

Clinical signs of peptic ulcer disease?

Answer 4

Epigastric tenderness
Pointing sign (able to point to where the pain is)

Question 5

Differences between duodenal and gastric ulcers?

Answer 5

Duodenal

• pain 2-3 hours after eating
• more commonly awakens patients at night
• Hx of often overeating = weight gain

Gastric

• pain shortly after eating
• Hx of often avoiding eating = weight loss

Question 6

Risk factors for peptic ulcer disease?

Answer 6

H. Pylori (developing countries)
NSAIDs (developed countries)

Others include age, bisphosphonates, smoking, burns, Zollinger-Ellison

Question 7

What type of bacterium is H. Pylori?

Answer 7

Gram-negative flagellate

Question 8

Tests for H. Pylori?

Answer 8

13C urea breath test (ingest urea then measure breath 13CO2 - positive result is high 13CO2)
Stool antigen

Question 9

Prep for H. Pylori breath test?

Answer 9

Stop PPIs beforehand

Question 10

Treatment for H. Pylori?

Answer 10

1 week triple therapy

- PPI + 2 ABx (amoxicillin + clarithromycin/metronidazole)

Question 11

What is Zollinger-Ellison syndrome?

Answer 11

Gastrinoma - tumour secreting gastrin in pancreas

Question 12

Pathophysiology of ZE syndrome?

Answer 12

• Hypergastrinaemia
• Hypertrophy of gastric mucosa + stimulation of acid-secreting cells
• Damaged mucosa + ulceration
  (90% of ZES patients will develop peptic ulcer)

Question 13

When should ZES be considered?

Answer 13

Multiple peptic ulcers refractory to treatment or FHx of MEN

Question 14

What endocrine condition is ZES associated with?

Answer 14

MEN - since ZES is due to a gastrinoma

Question 15

Management of ZES?

Answer 15

PPI

Surgical resection if required

Question 16

Investigation of suspected ZES?

Answer 16

Fasting serum gastrin (elevated)

Others

• serum calcium (checking for MEN)
• gastric acid secretory tests/stimulation tests/imaging

Question 17

Investigations of PUD?

Answer 17

Under 55 + no red flag symptoms

• breath test/stool antigen
• FBC, stool occult blood, serum gastrin

Over 55 +/- red flag symptoms +/- treatment failed

• UGI endoscopy
• histology/biopsy, urease testing
• repeat endoscopy after 6-8 weeks

Question 18

Upper GI red flag symptoms?

Answer 18

Weight loss
Bleeding
Anaemia
Vomiting
Early satiety
Dysphagia

Question 19

Management of PUD?

Answer 19

Risk factor modification
- diet, smoking, reduce alcohol/NSAIDs/bisphosphonates

Pharmacological

• H. Pylori positive = triple therapy
• H. Pylori negative = PPI (-oprazole’s) or H2 antagonist (-tidine’s)
• may need to treat/support anaemia

Question 20

Major complications of PUD and their management?

Answer 20

Haemorrhage

• endoscopy +/- therapy (adrenaline)
• IV PPI
• +/- blood transfusion (if substantial blood loss)

Perforation

• nil by mouth
• IV Abx
• +/- surgery to repair

Question 21

Complications of PUD?

Answer 21

• Haemorrhage
• Perforation
• Gastric outlet obstruction
• Scarring and stricturing
• Malignancy

Question 22

CXR sign of PUD complication?

Answer 22

Perforation can lead to peritonitis and/or pneumoperitoneum (air visible underneath diaphragm)