Peptic ulcer disease and gastritis

Question 1

What is peptic ulcer disease?

Answer 1

Ulceration of areas of the GI tract caused by exposure to gastric acid + pepsin.

Question 2

What are the 2 most common types of peptic ulcer? What other types exist?

Answer 2

Gastric
Duodenal
(can also occur in oesophagus + Meckel’s diverticulum).

Question 3

What is Meckels Diverticulum?

Answer 3

Outpouching or bulge in the lower part of the small intestine.
Congenital: a leftover of the umbilical cord

Question 4

Describe the aetiology of peptic ulcers?

Answer 4

Imbalance between damaging action of acid + pepsin + the mucosal protective mechanisms

Question 5

List 5 causes of peptic ulcers

Answer 5

Helicobacter pylori (chronic)
NSAIDs (acute)
Alcohol (acute) 
Bisphosphonates 
Smoking (acute)

Question 6

Describe the epidemiology of peptic ulcers

Answer 6

COMMON 
Annual incidence: 1-4/1000 
M > F
Duodenal ulcer: 30s 
Gastric ulcers: 50s 
H. pylori usually acquired in childhood + prevalence is ~equal to age in years

Question 7

List 3 symptoms of PUD

Answer 7

Epigastric pain: Relieved by antacids
Sx have a variable relationship to food intake
May present with complications e.g. haematemesis, melaena

Question 8

Name a rare cause of peptic ulcers. How would you investigate this? How would you treat it?

Answer 8

Zollinger-Ellison syndrome
Gastrin-secreting tumour or hyperplasia of islet cells in the pancreas cause overproduction of gastric acid, resulting in recurrent peptic ulcers
Ix: Fasting serum gastrin is measured + secretin test.
Tx: PPI + tumour resection

Question 9

Who are at higher risk of peptic ulcers? Why?

Answer 9

Shift workers as they tend to skip breakfast, inc. DRs who may also have stress risk factor.

Question 10

What signs may be present in someone with peptic ulcer disease?

Answer 10

May be NO physical findings
Epigastric tenderness
Signs of complications e.g. anaemia

Question 11

What investigations should be performed for a patient <55 with no red flags when suspecting peptic ulcers?

Answer 11

H pylori breath test/stool antigen test
FBC
Stool occult blood test
Serum gastrin (Zollinger Ellison syndrome)

Question 12

What investigations should be performed for a patient >55 or with red flags when suspecting peptic ulcers?

Answer 12

Upper GI endoscopy + biopsy (if gastric)

If ulcer is present: repeat endoscopy 6-8 weeks after tx to confirm resolution + exclude malignancy

Question 13

What bloods should be taken for peptic ulcers?

Answer 13

FBC (for anaemia)
Serum amylase (to exclude pancreatitis)
U+Es
Clotting screen
X-match if active bleeding
Secretin test (if Zollinger-Ellison syndrome suspected)

Question 14

Why perform an endoscopy in PUD?

Answer 14

Biopsies of gastric ulcers taken to exclude malignancy

Duodenal ulcers do NOT need to be biopsied

Question 15

Describe the 4 tests for H.pylori

Answer 15

1. Urea breath test:
   Orange juice then radio-labelled urea is given by mouth
   C13 is detected in the expelled air: as this means the urea has be broken down by urease (H pylori)
2. Serology
   IgG antibody against H. pylori confirms exposure to H. pylori but NOT eradication
3. Stool antigen test
4. Campylobacter-like organism (CLO) test:
   Gastric biopsy is placed with a substrate of urea + a pH indicator
   If H. pylori is present, ammonia is produced from the urea + there is a colour change from yellow to red

Question 16

Describe the acute management of peptic ulcers

Answer 16

Fluid resus needed if the ulcer is perforated or bleeding
Close monitoring of vital signs
Endoscopy
Surgical tx

Question 17

Describe the use of endoscopy in acute peptic ulcer management

Answer 17

If ulcer is bleeding, haemostasis can be achieved with:
Injection sclerotherapy
Laser coagulation
Electrocoagulation

Question 18

When is surgery indicated in acute peptic ulcer management?

Answer 18

Indicated if ulcer has perforated or if the bleeding ulcer can’t be controlled

Question 19

How is H.pylori eradicated in peptic ulcer disease?

Answer 19

Triple therapy for 1-2 weeks 
Various combinations, usually 2 abx + PPI (high dose) e.g.
Clarithromycin 500mg
Amoxicillin 1g/ metronidazole 400mg
Omeprazole

Question 20

Describe the management of peptic ulcer disease when not associated with H.pylori

Answer 20

PPIs (e.g. lanzoprazole) or H2 antagonists (e.g. ranitidine)
Stop NSAID/ bisphosphonates use
Use misoprostol (prostoglandin E1 analogue) if NSAID use is necessary

Question 21

If haemorrhage results from PUD, how may this present? How is this addressed?

Answer 21

Haematemesis (coffee-ground), melaena, IDA
Endoscopy :
Adrenaline injection (1:10,000)
May need IV PPI +/- blood transfusion

Question 22

If perforation results from PUD, how may this present? How is this managed ?

Answer 22

more commonly seen with duodenal (anterior + superficial zones)
Sudden sever epigastric pain which rad to shoulder, Vomiting + shock signs
Seen as air under diaphragm: pneumoperitoneum
NBM + Abx
Endoscopy: 1st line tx: adrenaline injection into bleeding site or clip application
If fails then cover with omental plug (surgical repair)
IV PPI may be needed later

Question 23

Why may obstruction result from PUD? In what forms? how may this present? How is this managed?

Answer 23

Due to scarring, penetration, pancreatitis
Pyloric stenosis: more in children
Cancers: more in elderly
Vomiting (undigested food), abdo distention, weight loss, malaise lethargy , met alkalosis
Resus, NG tube, endoscopy/ surgical intervention

Question 24

What is the prognosis in PUD?

Answer 24

Overall lifetime risk: 10%

Outlook good because peptic ulcers associated with H. pylori can be cured by eradication

Question 25

Which type of ulcer is more commonly associated with NSAID usage? How can this be avoided?

Answer 25

Gastric ulcers

Always give PPI with it or ask them to take with meals

Question 26

What is the relationship between symptoms and eating in gastric and duodenal ulcers?

Answer 26

Gastric: pain worse soon after eating
Duodenal: pain worse several hours after eating

Question 27

Describe the test used to detect Zollinger-Ellison syndrome

Answer 27

IV secretin causes a rise in serum gastrin in ZE pts but not in normal pts

Question 28

What must you ensure before testing for H pylori?

Answer 28

Needs to be 2 weeks PPI + Abx free when testing

Question 29

What should patients with upper GI bleeding be treated with at presentation until the cause of bleeding is identified?

Answer 29

IV PPIs