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yr 3 GI > peptic ulcer disease > Flashcards

peptic ulcer disease Flashcards

1
Q

definition of peptic ulcer disease

A

ulceration of areas of the GIT

caused by exposure to gastric acid and pepsis

most common: gastric and duodenal

can occur in oesophagus and Meckle’s diverticulum

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2
Q

aetiology of peptic ulcer disease

A

imbalance between damaging action of acid and pepsin, and mucosal protective mechanisms

strong correlation with Helicobacter pylori infection - unclear mechanism

common - very strong association with H pylori (95% of duodenal, 70-80% of gastric), NSAIDs

gastric cancer

rare - Zollinger-Ellison syndrome, crohn’s, sarcoidosis, TB

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3
Q

epidemiology of peptic ulcer disease

A

common

annual incidence 1-4/1000

males

duodenal - 30s

gastric ulcers - 50s

H pylori acquired in childhood and prevalence is equivalent to age in years

duodenal ulcer 4fold more common than gastric ulcer

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4
Q

sx of peptic ulcer disease

A

epigastric abdo pain (relieved by antacids) - related to hunger, specific foods, time of day, fullness after meals

radiate to back

heartburn - retrosternal pain

if worse soon after eating - gastric ulcer

if worse several hrs after eating - duodenal ulcer

+- weight loss

may present with complications:

  • haematemesis
  • melaena

beware ALARM Symptoms

can be asx - found incidentally or with crisis eg bleed

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5
Q

signs of peptic ulcer disease

A

may be no physical findings

epigastric tenderness

signs of complications:

  • anaemia
  • succession splash in pyloric stenosis
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6
Q

Ix for peptic ulcer disease

A

bloods

endoscopy

rockall scoring

testing for H pylori

histology of biopsy - difficult to visualise H pylori so limited value

for duodenal - measure gastrin concentrations when off PPI if Zollinger-Ellison syndrome is suspected

barium studies

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7
Q

bloods for peptic ulcer disease

A

FBC - low Hb (anaemia)

amylase - exclude pancreatitis

UE

clotting screen - if GI bleeding

LFT

cross match if actively bleeding

secretin test - if Zollinger-Ellison syndrome is suspected

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8
Q

secretin test

A

done if suspicion of zollinger-ellison syndrome

IV secretin = rise in serum gastrin in zollinger-ellison pts, but not in controls

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9
Q

endoscopy for peptic ulcer disease

A

4 quadrant gastric ulcer biopsies - rule out malignancy

repeat after 6-8wks to confirm healing and exclude malignancy

duodenal ulcers dont need to be biopsied

refer all with dysphagia, or >55 with ALARM Sx or treatment refractory dyspepsia

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10
Q

Rockall scoring - peptic ulcer disease

A

for severity after a GI bleed

<3 = good prognosis

>8 = high risk of mortality

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11
Q

testing for H pylori non-invasive

A

13C-urea breath test - radio-labelled urea given by mouth and detection of 13C in the expired air

serology - IgG Ab against H pylori - confirms exposure but not eradication

stool ag test - campylobacter-like organism test - gastric biopsy plaed with substrate of urea and a pH indicator - if H pylori is present - ammonia is produced from the urea and there is a colour change from yellow to red

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12
Q

acute Mx of peptic ulcer disease

A

resus if perforated or bleeding (IV colloids/crystalloids), close monitoring of vital signs, procedding endoscopic or surgical treatment

if upper GI bleeding - IV PPI (eg omeprazole or pantoprazole) at presentation until cause is confirmed

if actively bleeding peptic ulcer, or ulcer with high risk stigmata (eg visible vessel or adherent clot) - continue IV PPI

switch to oral PPI if no rebleeding within 24hrs

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13
Q

Mx for peptic ulcer disease

A

acute

drugs to reduce acid - PPI eg lansoprazole, or H2 blockers eg ranitidine

endoscopy - haemostatsis by injection sclerotherapy, laser or electrocoagulation

surgery if perf, or ulcer-related bleeding cant be controlled

H pylori eradication, and breath test to check for eradication

lifestyle - reduce alcohol and tobacco

follow up gastric ulcer with endoscopy 6-8wk - if not healed repeat biopsy to check for cancer

if extensive or recurrent ulceratoon consider unusual cause eg ZE

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14
Q

H pylori eradication

A

triple therapy for 1-02wks

1 PPI (eg lanosoprazole) and 2 AB (eg amoxicillin + clarithromycin, or Metronidazole + tetracycline)

less chance of recurrance and complications (bleeding) than if there is no eradication

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15
Q

Mx of peptic ulcer disease not associated with H pylori

A

treat with PPI or H2 antagonists

stop NSAIDS (especially diclofenac),

use misoprostol (prostaglandin E1 analogue) if NSAID use is necessary

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16
Q

Mx for drug induced ulcers

A

stop drug

PPIs for treating and preventing GI ulcers and bleeding in pts on NSAIDs or antiplatelet drusg

misoprostol is an alternative with diff SE

if sx persist - re-endoscope, retest for H pylori, reconsider ddx

surgery

17
Q

complications of peptic ulcer disease

A

rate of major complication is 1%/year including:

  • heamorrhage (haematemesis, melaena, IDA)
  • perforation
  • obstruction/pyloric stenosis (due to scarring, penetration, pancreatitis, strictures)
  • malignancy
  • reduced gastric outflow
  • recurrent ulceration
18
Q

prognosis of peptic ulcer disease

A

overall lifetime risk 10%

generally good Px becayse when associated by H pylori - can be treated by erradication

19
Q

ALARM Symptoms for peptic ulcer disease

A

anaemia - IDA

Loss of weight

Anorexia

Recent onset/progressive sx

Melaena/haematemesis

Swallowing difficulty

20
Q

RF for duodenal ulcer

A

H pylori - 90%

drugs - NSAIDs, steroids, SSRI

increased hastric acid secretion

increased hastric emptying - low duodenal pH

blood gp O

smoking

21
Q

sx of duodenal ulcer

A

asymptomatic

epigastric pain - relieved by antacids

+- reduced weight

22
Q

RF for gastic ulcers

A

H pylori - 80%

smoking

NSAIDs

reflux of duodenal contents

delayed gastric emptying

stress eg neurosurgery or burns - Cushing’s, or Curling’s ulcers

23
Q

RF for gastritis

A

alcohol

NSAIDs

H pylori

reflux/hiatus hernia

atrophic gastritis

granulomas - Crohn’s, sarcoidosis

CMV

zollinger-ellsion syndrome

Menetrier’s disease

24
Q

Sx of gastritis

A

epigastric pain

vomiting

25
Q

Ix for gastritis

A

upper Gi endoscopy only of suspicious features

26
Q

definition of gastritis

A

histological presence of gastric mucosal inflammation

27
Q

what is zollinger ellison syndrome

A

tumour of the endocrine pancreas – increase in gastrin production

= widespread ulceration to 2nd part of duodenum.

Rare for peptic ulcer disease because normally duodenal alkaline neutralse acid

28
Q

antrum predominant H pylori gastritis

A

live in stomach anf survive in brush border of the stomach

antrum predominant

gastric pathology - chronic inflammation and polymorph activity

increased acid output

duodenal pathology - gastric metaplasia, active chronic inflammation

peptic ulcer risk - distal gastric and duodenal ulcer – acid drip into duodenum -> gastric metaplasia - h pylori infect here = ulcer

29
Q

pangastrictis peptic ulcer

A

gastric pathology - chronic inflammation, polymorph activity, atrophy, intestinal metaplasia

Decreased acid output – suppression of acid secretion

Associated with gastric ulcer and cancer

If ulcer in body or fundus of stomach need to be V concerned

30
Q

association of H pylori with gastric cancer

A

pan-gastritis linked to development of gastric cancer

adenocarcinoma of corpus and antrum and MALT lymphoma

cure lymphoma by eradicating H pylori

causal relationship

31
Q

endoscopy based invasive tests for H pylori

A

rapid urease test – helicobacter produce urease – gel with coloured urea – if break down it changes colour yellow-> red

direct microscopy

histology

culture

DNA probes/PCR

32
Q

endoscopy of NSAID peptic ulcer

A

multiple small ulcers

yr 3 GI (52 decks)

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