Peptic ulcer disease and gastritis Flashcards
What is peptic ulcer disease?
Ulceration of areas of the GI tract caused by exposure to gastric acid + pepsin.
What are the 2 most common types of peptic ulcer? What other types exist?
Gastric
Duodenal
(can also occur in oesophagus + Meckel’s diverticulum).
What is Meckels Diverticulum?
Outpouching or bulge in the lower part of the small intestine.
Congenital: a leftover of the umbilical cord
Describe the aetiology of peptic ulcers?
Imbalance between damaging action of acid + pepsin + the mucosal protective mechanisms
List 5 causes of peptic ulcers
Helicobacter pylori (chronic) NSAIDs (acute) Alcohol (acute) Bisphosphonates Smoking (acute)
Describe the epidemiology of peptic ulcers
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
List 3 symptoms of PUD
Epigastric pain: Relieved by antacids
Sx have a variable relationship to food intake
May present with complications e.g. haematemesis, melaena
Name a rare cause of peptic ulcers. How would you investigate this? How would you treat it?
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
Who are at higher risk of peptic ulcers? Why?
Shift workers as they tend to skip breakfast, inc. DRs who may also have stress risk factor.
What signs may be present in someone with peptic ulcer disease?
May be NO physical findings
Epigastric tenderness
Signs of complications e.g. anaemia
What investigations should be performed for a patient <55 with no red flags when suspecting peptic ulcers?
H pylori breath test/stool antigen test
FBC
Stool occult blood test
Serum gastrin (Zollinger Ellison syndrome)
What investigations should be performed for a patient >55 or with red flags when suspecting peptic ulcers?
Upper GI endoscopy + biopsy (if gastric)
If ulcer is present: repeat endoscopy 6-8 weeks after tx to confirm resolution + exclude malignancy
What bloods should be taken for peptic ulcers?
FBC (for anaemia)
Serum amylase (to exclude pancreatitis)
U+Es
Clotting screen
X-match if active bleeding
Secretin test (if Zollinger-Ellison syndrome suspected)
Why perform an endoscopy in PUD?
Biopsies of gastric ulcers taken to exclude malignancy
Duodenal ulcers do NOT need to be biopsied
Describe the 4 tests for H.pylori
- 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) - Serology
IgG antibody against H. pylori confirms exposure to H. pylori but NOT eradication - Stool antigen test
- 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
Describe the acute management of peptic ulcers
Fluid resus needed if the ulcer is perforated or bleeding
Close monitoring of vital signs
Endoscopy
Surgical tx
Describe the use of endoscopy in acute peptic ulcer management
If ulcer is bleeding, haemostasis can be achieved with:
Injection sclerotherapy
Laser coagulation
Electrocoagulation
When is surgery indicated in acute peptic ulcer management?
Indicated if ulcer has perforated or if the bleeding ulcer can’t be controlled
How is H.pylori eradicated in peptic ulcer disease?
Triple therapy for 1-2 weeks Various combinations, usually 2 abx + PPI (high dose) e.g. Clarithromycin 500mg Amoxicillin 1g/ metronidazole 400mg Omeprazole
Describe the management of peptic ulcer disease when not associated with H.pylori
PPIs (e.g. lanzoprazole) or H2 antagonists (e.g. ranitidine)
Stop NSAID/ bisphosphonates use
Use misoprostol (prostoglandin E1 analogue) if NSAID use is necessary
If haemorrhage results from PUD, how may this present? How is this addressed?
Haematemesis (coffee-ground), melaena, IDA
Endoscopy :
Adrenaline injection (1:10,000)
May need IV PPI +/- blood transfusion
If perforation results from PUD, how may this present? How is this managed ?
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
Why may obstruction result from PUD? In what forms? how may this present? How is this managed?
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
What is the prognosis in PUD?
Overall lifetime risk: 10%
Outlook good because peptic ulcers associated with H. pylori can be cured by eradication
Which type of ulcer is more commonly associated with NSAID usage? How can this be avoided?
Gastric ulcers
Always give PPI with it or ask them to take with meals
What is the relationship between symptoms and eating in gastric and duodenal ulcers?
Gastric: pain worse soon after eating
Duodenal: pain worse several hours after eating
Describe the test used to detect Zollinger-Ellison syndrome
IV secretin causes a rise in serum gastrin in ZE pts but not in normal pts
What must you ensure before testing for H pylori?
Needs to be 2 weeks PPI + Abx free when testing
What should patients with upper GI bleeding be treated with at presentation until the cause of bleeding is identified?
IV PPIs
