Peptic Ulcer Disease

Question 1

What are the types of peptic ulcers?

Answer 1

• Gastric ulcers
• Duodenal ulcers (more common)

Question 2

What causes PUD?

Answer 2

• H.Pylori (most common)
• NSAIDs(most common)
• Steroids, biphosphonates, SSRI
• Alcohol, smoking
• caffeine
• Zollinger-Ellison Syndrome - only for duodenal ulcer

Question 3

How does Zollinger Ellison Syndrome causes PUD?

Answer 3

1. ZES is a Neuroendocrine tumour in duodenal wall
2. Secretes excessive gastrin
3. Gastrin stimulates Parietal cells to secrete HCL

Question 4

Where does gastric ulcers typically occur?

Answer 4

• lesser curvature of stomach

Question 5

What is the presentation of PUD?

Answer 5

• Epigastric pain
• Nausea and vomiting
• Dyspepsia
• heartburn
• Bleeding causing haematemesis, “coffee ground” vomiting and melaena
• Iron deficiency anaemia (due to constant bleeding)

Question 6

What is the difference between gastric ulcers and duodenal ulcers in terms of pain and eating?

Answer 6

• Gastric ulcer: pain worsen on eating > loss weight
• Duodenal ulcer: pain relieved on eating > gain weight

Question 7

Which ulcer has a high risk of carcinoma?

Answer 7

• Gastric ulcer

Question 8

What Ix would you order for PUD?

Answer 8

Bedside

• Obs
• H.Pylori test
  
  • breath test, stool antigen test,
• ECG

Bloods

• FBC - iron def. anaemia
• LFT
• Serological H.pylori test - IgG against h pylori

Special

• OGD + biopsy
  
  • Urease test (CLO test)
  • Histology - gram staining
  • Culture - abx sensitivity

Question 9

How would you Mx PUD?

Answer 9

• Lifestyle
  
  • avoid triggers
  • lose weight
  • avoid alcohol and smoking
• H.Pylori eradication
  
  • Triple therapy’
• Non H.pylori related
  
  • Full dose PPI 4-8weeks
• Stop drug induced ulcers

Question 10

What are the Cx of PUD?

Answer 10

• Bleeding
• Perforation
  
  • If suspected > CXR for pneumoperitoneum
• Haemorrhage
• Gastric outlet obstruction

Question 11

What is the triple therapy for H.Pylori eradication?

Answer 11

First line eradication (7days)

• Omeprazole
• Amoxicillin 1g
• Metronidazole 400mg
• If penicillin allergy, use Clarithromycin instead

Second line eradication - if first one fails

• Proton pump inhibitor
• Amoxicillin
• Clarithromycin/metronidazole
• Quinolone/tetracycline

If second line fails - refer to secondary care

Question 12

What are the features of H.Pylori?

Answer 12

• gram negative
• spiral-shaped, flagellated, micro-aerophilic bacterium
• Enzyme urease
  
  • convert urea to H2O and ammonia
• Adherence
  
  • flagella of H pylori propel bacterium towards apical surface
• Virulence factor
  
  • VacA - affects host cell permeability and induces apoptosis

Question 13

Which part of stomach does H.Pylori colonise?

Answer 13

• antrum

Question 14

What is H.pylori associated with?

Answer 14

• Gastric lymphoma
• Gastric adenocarcinoma

Question 15

How would PUD present acutely?

*think acute UGIB and perforation signs

Answer 15

• Acute UGIB
  
  • Haematemesis +/- melaena
  • Features of shock may be present
• Perforation
  
  • Acute, severe abdominal pain & tenderness
  • Localised or generalised guarding
  • Features of shock may be present

Question 16

Gastric outlet obstruction may occur in PUD secondary to stricturing. What are the cf?

Answer 16

• nausea
• vomiting
• upper abdominal pain
• Tenderness,
• distention
• succussion splash