Peptic Ulcer Disease

Question 1

Define peptic ulcer

Answer 1

A break in the lining of the GI tract extending thorugh the muscular layer (muscularis mucosae) of the bowel wall.

Diagnosis is endoscopic

Question 2

Where do peptic ulcers commonly occur?

Answer 2

Lesser curvature of the proximal stomach

First part of the duodenum.

Question 3

Epidemiology

Answer 3

0.1-0.2% of the population per year

Duodenal ulcers classically present earlier than gastric ulcers

Question 4

Causes

Answer 4

When there is imbalance between the factors that protect the mucosa (surface mucous secretion and HCO3- release e.g.) and factors that damage it (NSAIDs, H. pylori etc…)

Question 5

How do NSAIDs cause peptic ulcers?

Answer 5

Inhibiting prostaglandin synthesis leading to reduced secretion of glycoprotein, mucous and phospholipids by the gastric epithelial cells.

Question 6

What is H. pylori?

Answer 6

G- spiral shaped bacillus found in the mucous layer of those with duodenal ulcers (90%) or gastric ulcers (70%).

Question 7

How does H. pylori survive in the stomach?

Answer 7

Producing an alkaline microenvironment

Question 8

How does H. pylori destroy the stomach lining?

Answer 8

Invoking a cytokine and interleukin-driven inflammatory response

Increasing gastric acid secretion by inducing release of histamine which acts on parietal cells

Damaging host mucous secretion by degrading surface glycoproteins and down-regulating bicarbonate production

Question 9

Risk factors of peptic ulcer disease

Answer 9

H. pylori infection

Prolonged NSAIDs use

Corticosteroids

Gastric bypass

Physiological stress

Head trauma (cushing’s ulcer)

Severe burns (curling’s ulcer)

Zollinger-Ellison syndrome

Question 10

Clinical features

Answer 10

70% asymptomatic

Epigastric or retrosternal pain exacerbated by eating

Nausea

Bloating

Post-prandial discomfort or early satiety

Can also present with complications such as bleeding, perforation or gastric outlet obstruction.

Question 11

How does pain associated with eating differ between gastric ulcers and duodenal ulcers?

Answer 11

Gastric = Exacerbated by eating straight away

Duodenal = Worse 2-4 hours after eating or can even be alleviated by eating

Question 12

Indications of urgent OGD according to NICE

Answer 12

New-onset dysphagia

>55 yo with weight loss and either upper abdo pain, reflux or dyspepsia

New onset dyspepsi not responding to PPi

Question 13

Dx

Answer 13

ACS

GORD

Gallstone disease

Gastric malignancy

Pancreatitis

Question 14

Explain Zollinger-Ellison syndrome

Answer 14

Triad of:

Severe peptic ulcer disease

Gastric acid hypersecretion

Gastrinoma

(Gastrin level >1000 pg/ml)

A third of these cases are discovered as part of multiple endocrine neoplasia type 1 syndrome so further investigations for MEN syndrome are warranted (pancreas, pituitary, parathyroid tumours)

Question 15

Investigations

Answer 15

Many do not require OGD and can be treated empirically initially.

FBC

Non-invasive H. pylori testing

In older -> OGD should be done if refractory to treatment

Question 16

OGD in peptic ulcer disease

Answer 16

Any peptic ulceration should be biopsied and sent for histology + rapid urease test.

Question 17

What non-invasive H. pylori tests are there?

Answer 17

Carbon-13 urea breath test

Serum antibodies to H. pylori

Stool antigen test

Question 18

What does NICE recommend about gastric ulcers on endoscopy.

Answer 18

That they should be biopsied and that a repeat endoscopy should be performed towards the end of PPi therapy to check for resolution.

Question 19

What is important to do 2 weeks prior to H. pylori testing?

Answer 19

Stop any current medical therapy for 2 weeks to reduce the risk of false negatives.

Once H. pylori has been identified no further investgations are usually needed.

Question 20

Conservative general management of peptic ulcer disease

Answer 20

Lifestyle advice

Smoking cessation

Weight loss

Reduction in alcohol consumption

Do not take NSAIDs

Question 21

Conservative management

Answer 21

Suspected or confirmed ulcers can be started on PPis for 4-8 weeks to reduced acid production.

Then reassessed after this period for resolution of symptoms.

Question 22

Treatment of +ve H. pylori peptic ulcer disease

Answer 22

Triple therapy with PPi, oral amoxicillin and clarithromycin/metronidazole for 7 days.

Question 23

Management of persistence of symptoms post-PPi +/- eradication therapy.

Answer 23

First line = urgent OGD to exclude malignancy.

Question 24

Surgical management

Answer 24

Rare to perform

Done in emergencies or in the management of Zollinger-Ellison syndrome

Severe or relapsin disease either partial gastrectomy or selective vagotomy may be considered.

Question 25

Complications

Answer 25

Perforation

Haemorrhage

Pyloric stenosis