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general surgery > Peptic Ulcer Disease > Flashcards

Peptic Ulcer Disease Flashcards

1
Q

What is a peptic ulcer?

A

A break in the lining of the GI tract, extending through to the muscular layer (muscularis mucosae) of the bowel wall

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2
Q

Where is the most common location of a peptic ulcer?

A

Lesser curvature of the proximal stomach

OR

First part of the duodenum

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3
Q

What is the pathophysiology of peptic ulcers?

A

Imbalance between factors that promote mucosal damage and the mechanisms that promote gastroduodenal defence.

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4
Q

What factors promote damage to the gastroduodenal mucosa?

A
  • Gastric acid
  • Pepsin
  • H. Pylori
  • NSAIDs
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5
Q

What are the mechanisms that protect the gastroduodenal mucosa?

A
  • Prostaglandins
  • Mucus
  • Bicarbonate
  • Mucosal blood flow
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6
Q

What are risk factors for peptic ulcer disease?

A
  • NSAID use
  • H. pylori infection
  • Increasing age
  • Smoking
  • Personal / Family history of peptic ulcer disease
  • Intensive care stay
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7
Q

What are the most common causes of peptic ulcers?

A

H.Pylori

NSAIDs

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8
Q

How does NSAID use cause peptic ulcers?

A

Inhibits prostaglandin synthesis, resulting in reduced gastro-protective secretion of glycoprotein, mucous, and phospholipids by the gastric epithelial cells.

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9
Q

What is Helicobacter pylori?

A

A Gram -ve spiral-shaped bacillus, found in the mucous layer of those with duodenal ulcers (90%) or gastric ulcers (70%)

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10
Q

How does H. Pylori cause peptic ulcers?

A

It produces an alkaline micro-environment & induces an inflammatory response in the mucosa, leading to eventual ulceration, by:

  • Invoking an cytokine and interleukin-driven inflammatory response
  • Increasing gastric acid secretion in both the acute and chronic phases of infection, by inducing the release of histamine which acts on parietal cells
  • Damaging host mucous secretion by degrading surface glycoproteins and down-regulating bicarbonate production
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11
Q

Aside from NSAID use & H. Pylori infection, what are other causes of peptic ulcer disease?

A
  • Certain medications
    • Corticosteroids (when used with NSAIDs)
    • SSRIs
    • Bisphosphonates
  • Zollinger-Ellison syndrome (rare)
  • Prev. gastric bypass surgery
  • Physiological stress, such as:
    • Gastric ischaemia
    • Head trauma (Cushing’s ulcer)
    • Severe burns (Curling’s ulcer)
  • Crohn’s
  • Infection (e.g. HIV, herpes)
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12
Q

What is Zollinger-Ellison Syndrome?

A

Triad of:

  1. Severe peptic ulcer disease
  2. Gastric acid hyper-secretion
  3. Gastrinoma
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13
Q

What percentage of peptic ulcers are asymptomatic?

A

Up to 70%

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14
Q

What symptoms can peptic ulcer disease present with?

A
  • Epigastric or retrosternal pain (Dyspepsia)
    • Can radiate through to back w duodenal ulcers that penetrate into pancreas
  • Nausea & vomiting
  • Bloating
  • Post-prandial discomfort (Pain after meals)
  • Early satiety
  • Complications of peptic ulcer disease (less common)
    • Bleeding
    • Perforation
    • Gastric outlet obstruction
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15
Q

How is the typical pattern of pain different between gastric ulcers and duodenal ulcers?

A

Gastric ulcers = Pain WORSENED by eating

Duodenal ulcers = Pain RELIEVED by eating (or worse 2-4 hrs after)

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16
Q

What are differential diagnoses for peptic ulcer disease?

A

Any condition that causes dyspepsia, chest pain, or epigastric pain:

  • ACS
  • Gastro-oesphageal reflux
  • Gallstone disease
  • Gastric malignancy
  • Pancreatitis
17
Q

What is NICE guidance on referral for urgent upper Oesophago-Gastro-Duodenoscopy (OGD)?

A

Should be done for patients presenting with either:

  1. New-onset dysphagia
  2. Aged > 55 w/ weight loss & one of: upper abd pain, reflux or dyspepsia
  3. New onset dyspepsia not responding to PPI treatment
18
Q

What investigations are indicated when peptic ulcer disease presents?

A
  1. FBC - To assess for potential anaemia
  2. Non-invasibe H. pylori testing (1st line test for H. Pylori)
  • Carbon-13 urea breath test
  • Serum antibodies to H. pylori
  • Stool antigen test
  1. OGD (Oesophago-Gastro-Duodenoscopy)
  • For patients who:
    • Are older
    • Have red flag symptoms
    • Have ongoing symptoms despite empirical treatment

Biopsy & histology done during endoscopy if peptic ulceration present to:

  1. Look for malignancy
  2. Carry out rapid urease test
19
Q

What is a rapid urease test and how does it work?

A

Also known as a CLO test (Campylobacter-like organism test), it’s a rapid diagnostic test for diagnosis of Helicobacter pylori.

Biopsy of mucosa is taken from the antrum of the stomach, and is placed into a medium containing urea and an indicator such as phenol red. The urease produced by present H. pylori hydrolyzes urea to ammonia, which raises the pH of the medium, and changes the color of the specimen from yellow (NEGATIVE) to red (POSITIVE).

20
Q

What is the NICE guidance on biopsy of gastric ulcers?

A

Recommends that all identified gastric ulcers are biopsied, due to malignant potential, and that a repeat endoscopy is performed towards the end of PPI therapy to check for resolution.

21
Q

How should patient’s prepare for a H. Pylori test?

A

Patients should stop any current medical therapy for 2 weeks prior to investigation to reduce the risk of false negatives.

22
Q

What is the conservative management of peptic ulcers?

A
  1. Lifestyle advice to reduce symptoms, such as:
  • Smoking cessation
  • Weight loss
  • Reduction in alcohol consumption
  • Avoidance / cessation of NSAIDs where possible.
  1. Proton Pump Inhibitor for 4-8 wks (When -ve H. Pylori)
    * To reduce acid production in patients w/ suspected or confirmed ulcers

Always reassess after this period for resolution of symptoms (“Test and Treat”).

  1. Triple therapy / Eradication therapy (when +ve H. Pylori)
    * PPI w/ oral amoxicllin + clarithromycin/metronidazole for 7 days
  2. Persistence of symptoms despite treatment warrants further work-up
  • First line = Urgent OGD
    • To exclude any malignancy.
  • Consider other causes such as failure of H. pylori eradication or Zollinger-Ellison Syndrome.
23
Q

What is the surgical management of peptic ulcer disease?

A

RARE

Except in emergencies (e.g. perforation) or in the management of Zollinger-Ellison Syndrome.

BUT consider partial gastrectomy / selective vagotomy in severe or relapsing disease.

24
Q

What are the complications of peptic ulcer disease?

A
  • Perforation
  • Haemorrhage
  • Pyloric stenosis (Gastric outlet obstruction)
  • Penetration (into other organs, i.e pancreas)

general surgery (12 decks)

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