Peptic Ulcer Disease

Question 1

What is affected by peptic ulcer disease

Answer 1

Any acid affected site:
Oesophagus
Stomach
Duodenum

Question 2

What are the causes of PUD

Answer 2

High acid secretion

Loss of ability to defend against acid attacks

Question 3

Describe how high acid secretion causes PUD

Answer 3

Upregulation of gastrin produces acid secretion long after food stimulation is gone
The excess acid causes ulcers to develop

Question 4

Describe how normal levels of acid secretion can lead to PUD

Answer 4

There may be a reduced protective barrier to the stomach lining
The thin layer of mucus can be removed by drugs such as NSAIDS or steroids, but also by the bacteria Heliobacter pylori

Question 5

What is a peptic ulcer

Answer 5

A burn which burns deep into tissues which may eventually extend through to erode an artery or potentially can go straight through the viscous wall and into the peritoneum - a perforated ulcer

Question 6

Describe the trend between peptic ulcers and age

Answer 6

Incidence increases up to about age 50 then starts to fall again

Question 7

Describe how H.pylori can cause a peptic ulcer to form

Answer 7

Bacteria gets into the protective mucous, removes it and allows acid attack and inflammation to happen within the stomach lining

Question 8

What are the effects of H.pylori

Answer 8

Gastric ulcers

Chronic gastric wall inflammation - lymphoma of the stomach

Question 9

Why is chronic gastric wall inflammation considered a mucosa associated lymphoid tumour (MALT)

Answer 9

If you remove the cause, the lymphoma will disappear

Question 10

How is H.pylori eliminated

Answer 10

Triple therapy:
2 antibiotics - usually amoxicillin with metronidazole
1 proton pump inhibitor - usually omeprazole
Given for 2 weeks

Question 11

What are the signs and symptoms of PUD

Answer 11

Often none
Epigastric burning pain
Signs usually only present when complications are present such as bleeding or perforations

Question 12

Describe epigastric burning pain

Answer 12

Worse before or just after meals
Worse at night
Relieved by food, alkali and vomiting

Question 13

What investigations can be carried out for PUD

Answer 13

Endoscopy - allows visualisation of the tissues and a biopsy to be taken to check for H.pylori
Radiology - barium meal
Anaemia - FBC and FOB
H.pylori test - breath, antibodies and mucosa

Question 14

What systemic complications can be caused by PUD

Answer 14

Anaemia

Question 15

What local complications can be caused by PUD

Answer 15

Perforation
Haemorrhage
Stricture
Malignancy

Question 16

Describe the consequences of a haemorrhage caused by PUD

Answer 16

Erosion of the ulcer into a blood vessel will cause bleeding into the stomach leaving a large quantity of blood in the stomach which can be vomited up
It is often brown and granular - coffee ground vomit
If found it should always trigger an endoscopy quickly as there may be a significant vessel bleeding

Question 17

Describe the consequences of stricture caused by PUD

Answer 17

Stricture may form as the chronic irritation and ulceration heal by secondary intention
If this produces a scar which contracts it can reduce the size of the exit from the stomach

Question 18

What medical treatments can be carried out for PUD

Answer 18

Smoking cessation
Small regular meals
H.pylori eradication therapy
Ulcer healing drugs - proton pump inhibitors

Question 19

What surgical treatments can be carried out for PUD and why may they be carried out

Answer 19

Endoscopy - to decide whether a surgical or medical approach is most effective
Surgical excision - excision of the ulcer through a partial gastrectomy - now considered last resort
Vagotomy to reduce acid secretion by dividing the vagus nerve

Question 20

When should surgical treatment be carried out for PUD

Answer 20

Following an acute event:
Stricture
Acute bleed
Perforation
Malignancy

Question 21

What types of medication can be used to treat PUD

Answer 21

H2 receptor blockers and proton pump inhibitors to reduce acid secretion
Eliminate H.pylori and use prostaglandin inhibitors to improve the mucosal barrier

Question 22

What must happen after triple therapy

Answer 22

H.pylori must be tested through either endoscopy and biopsy or through breath testing

Question 23

What different surgeries are available for PUD

Answer 23

Bilroth 1
Bilroth 2
Vagotomy

Question 24

Describe Bilroth 1 surgery

Answer 24

Allowed excision of part of the stomach and then anastomoses of the duodenum to the remaining part of the stomach

Question 25

What is the problem with Bilroth 1 surgery

Answer 25

No sphincter from the stomach to the duodenum so food can flow freely

Question 26

Describe Bilroth 2 surgery

Answer 26

Same stomach excision as Bilroth 1 but instead the stomach empties further down into the duodenum which causes less problems

Question 27

What is the problem with Bilroth 2 surgery and how is it resolved

Answer 27

Bind loop can cause bacterial proliferation but the pancreatic and biliary secretions still flow into this and keep moving the contents down

Question 28

Describe a vagotomy

Answer 28

By dividing the branches from the main vagal trunk passing into the stomach wall, the acid secretion caused by the neurological trigger can be reduced