Peptic Ulcer disease and Gastritis

Question 1

Define Peptic Ulcers

Answer 1

Break in the superficial epithelial lining of either stomach (gastric) or duodenum (more common)

Question 2

Aetiology of Peptic Ulcers

Answer 2

H. Pylori 
NSAIDs 
Zollinger-Ellison syndrome 
ICU stays and gastric ischaemia (-> stress ulcers)
CMV in HIV patients

H. pylori: gastric mucin degradation, disrupted TJ between cells and induction of gastric cell death

NSAIDs: inhibits COX -> inhibits prostaglandins secretion -> mucosal damage

Question 3

What is the difference between Antrum-predominant and Pan-gastritis

Answer 3

Antrum-predominant: chronic inflammation and polymorph activity where there is INCREASED acid output, Gastric metaplasia in the duodenum + duodenal ulcers

Pan-gastritis: Chronic inflammation, polymorph activity, atrophy and intestinal metaplasia where there is REDUCED acid output, normal duodenal pathology and association with gastric ulcers and cancers

Question 4

Risk factors for Peptic Ulcers

Answer 4

H. pylori 
NSAIDs
Family history 
Increasing age
Smoking
Alcohol 
Psychological stress

Question 5

Epidemiology of Peptic Ulcers

Answer 5

Incidence increases with age
Duodenal ulcers appear slightly younger
Common in developing countries where H. pylori is more relevant (80%)
Duodenal ulcers are more common and 95% are due to H. pylori

Question 6

Symptoms of Peptic Ulcers

Answer 6

Dyspepsia
Abdominal pain: associated with eating (Gastric + immediate, duodenal + 3h after/at night) | May be relieved by antacids
Nausea and vomiting
Early satiety 
Anorexia and weight loss
Possible weight fain (duodenal)

Rupture: melaena, coffee-ground vomit
Zollinger-Ellison: Diarrhoea, abdominal pain, multiple duodenal ulcers, MEN

Question 7

Signs of Peptic ulcer on examination

Answer 7

Production of melaena and coffee-ground vomit

“pointing sign” can pinpoint pain

Question 8

What is the red flag referral for peptic ulcer symptoms

Answer 8

> 55 + weight loss
60 + anaemia, haematemesis, melaena, early satiety, dysphagia, odynophagia

-> 2 week wait endoscopy to rule out UGI malignancy

Question 9

Investigations for Peptic Ulcers

Answer 9

1. H. pylori testing (Urea Breath test | Stool antigen test | Serology)
2. OGD (gold standard): ulcerating or exophytic mucosal lesions that may sorrow the lumen + biopsy

FBC: anaemia
U+Es: elevated urea
Amylase/lipase: exclude pancreatitis
Fasting gastrin level: Raised in Zollinger-Ellison syndrome

Erect CXR: check for perforation (pneumoperitoneum)
AXR: Check for perforation

Question 10

Management for Peptic Ulcers

Answer 10

Lifestyle management: avoid spicy food, alcohol, late meals, big meals, Smoking cessation

H. pylori: Triple therapy (1x PPI, 2x 7 day Abx course e.g. clarithromycin/metronidazole + amoxicillin)
+ Re-test after abs course with breath test

H. pylori -ve: PPI or H2RA 4-8 weeks (+ ranitidine)
Stop any NSAID use

Endoscopy +ve: eradication therapy + 4-8 weeks PPI/H2RA
6-8 weeks - Urea breath test + repeat endoscopy
Consider Malignancy, Crohn’s, drugs, Zollinger-Ellison syndrome, GIST if non-healed

Question 11

Complications of Peptic Ulcers

Answer 11

Pancreatitis 
Haematemesis 
SOB and syncope
Massive GI bleed, shock and syncope
Peritonitis 
Pylori stenosis/gastric outlet obstruction
Malignancy

Question 12

Prognosis for Peptic Ulcers

Answer 12

With PPI: Duodenal heals its 4 weeks and gastric within 8 weeks
Recurrence risk 20-30% with H. pylori
Good prognosis if NSAID use is discontinued