Peptic ulcer disease/dyspepsia

Question 1

define PUD?

Answer 1

• break in the mucosal lining of the stomach or duodenum
• >5 mm, into submucosa (smaller = erosions)
Duodenal ulcers (DU) are commoner than gastric ulcers (GU). resulting from mucosal damage (H+, pepsin, H. pylori infection, NSAIDs) + poor defense (prostaglandins, mucus, HCO3, mucosal blood flow)

Question 2

Hx: pt presents with chronic, upper abdominal pain related to eating a meal (dyspepsia), and at night. with N. +/- weight loss

Ex: epigastric tenderness, pallor conjunctivae

Answer 2

PUD

Question 3

causes?

Answer 3

NSAIDs

Helicobacter pylori

Question 4

causes?

Answer 4

• Helicobacter pylori (80 percent, mostly duodenal)
• NSAIDs (20 percent, mostly gastric)
• Steroids
• Alcohol, smoking
• FHx
• Stress

Question 5

complications?

Answer 5

• gastroduodenal bleeding (commonest, occult - stool haem test positive - or overt - haematemesis +/- melaena)
• perforation (life-threatening)
• gastric outlet obstruction (pyloric stenosis, presents with vomiting)

Either of these may be the presenting symptom, particularly in patients taking NSAIDs.

Question 6

if Hx includes:-
• N relieved by eating
• V occurs after eating
• early satiety

Answer 6

may indicate pyloric stenosis

Question 7

risk factors for PUD?

Answer 7

• H pylori
• NSAIDs
• smoking
• age
• FHx
• ITU

Question 8

Ix PUD?

Answer 8

BEDSIDE
• H pylori 13C urea breath test or stool antigen test (Ix in all patients <55)
- Stop PPIs 2 weeks before test.
• faecal occult blood test

BLOODS
• FBC (iron-deficiency anaemia)

IMAGING/SPECIAL
• endoscopy (if ≥60 years/≥55 + alarm Sx), repeated 6-8 wks
• biopsy: histology for cancer and CLO test (aka rapid urease test) for H. pylori
• stop PPIs 2 weeks before test

Question 9

Tx PUD, with active bleeding ulcer?

Answer 9

endoscopy ± blood transfusion + PPI

embolisation if fails

Question 10

Tx PUD no active bleeding: H pylori negative?

Answer 10

• stop NSAIDs (likely cause), alcohol, smoking
• Tx cause (functional non-ulcer dyspepsia is common_
• PPI

Question 11

Tx PUD no active bleeding: H pylori positive?

Answer 11

• less alcohol and smoking
• H pylori eradication therapy:
- PPI + clarithromycin + amox/metro for 14 days

Question 12

are gastric or duodenal ulcers more common?

Answer 12

Duodenal ulcers (DU) are commoner than gastric ulcers (GU)

Question 13

Sx pain difference between gastric and duidenal?

Answer 13

• gastric ulcer, shortly after
• duodenal ulcer, somewhat later (2-3 hours), more likely to wake at night, eating itself may initially relieve the pain, may radiate through to back

“DU takes her time and gets back reflux at night”

Question 14

when a 2 week endoscopy referral for dyspepsia?

Answer 14

alarm signs for gastric or oesophageal cancer:
• >55 years old at onset (and persistent)
• persistent vomiting
• dysphagia
• weight loss
• upper GI bleeding (or iron-deficiency anaemia)
• epigastric mass

Question 15

ulcer prevention in high risk patients?

Answer 15

• PPIs if on long term steroids

* avoid long-term NSAIDs

Question 16

Tx dyspepsia?

Answer 16

• review meds (and maybe stop NSAIDs)
• lifestyle changes for 1 month (stop smoking and alcohol)
• endoscopy if there are alarm signs
• H. pylori test and treat if PUD suspected (rather than GORD) i.e. epigastric pain predominates

Question 17

how to test for and Tx H pylori?

Answer 17

• test +ve, give triple therapy: 2 months of PPI plus 1 week of {clarithromycin} + {amoxicillin or metronidazole}
• test -ve, give 1-2 months of PPI
• follow up endoscopy: if diagnosis was originally by endoscopy and it was a GASTRIC ulcer, (cancer can present with ulcer)
• DUODENAL ulcers only need checking if unresponsive to treatment

Question 18

indications for surgery in ulcers?

Answer 18

• ulcer refractory to medical treatment
• bleeding ulcer
• perforated ulcer
• gastric outlet obstruction

Question 19

Hx: patient presents with acute abdomen: in severe 10/10 pain: epigastric then quickly generalised, with shock, peritonitis, lying still in pain +/- V

Answer 19

perforated ulcer

ΔΔ pancreatitis if V more than a couple of times

Question 20

Ix and Tx a perforated ulcer?

Answer 20

IMAGING
• erect CXR: pneumoperitoneum
• abdo CT

Tx
• ‘drip and suck’: IV fluids, and NG tube to empty stomach
• PPIs and Abx
• subsequent H. pylori eradication
• peritoneal washout and surgical repair
• sometimes excision and biopsy if ulcer is gastric, as some are malignant

Question 21

Hx: epigastric pain, N, V +/- D, +/- upper GI bleeding

Ix: no ulcers on endoscopy

• diagnosis?
• risk factors?

Answer 21

• gastritis
(Tx as for PUD, including Sx relief with anti acid medications and H. pylori eradication if present)

• alcohol, NSAIDs, H pylori, reflux

Question 22

“ALARMS” Sx to ask about in dyspepsia?

Answer 22

• anaemia (Fe def)
• loss of weight
• anorexia
• recent onset/progressive
• malaena/haematemesis
• swallowing difficulty

Question 23

duodenal vs gastric ulcer?

Answer 23

• duodenal

• commonest
• H pylori, drugs
• pain 2-3 hours later, nocturnal, meal may relieve

• gastric

• rarer, in elderly
• H pylori, smoking, NSAIDS
• pain shortly after

Question 24

ΔΔ dyspepsia

Answer 24

• duodenal ulcer
• gastric ulcer
• non-ulcer dyspepsia
• duodenitis
• gastritis
• gastric CA
• oesophagitis/GORD

(duodenal Crohn’s, TB, lymphoma, pancreatic Ca)

Question 25

examples of Ix for H pylori? (non-invasive vs invasive)

Answer 25

* non-invasive (C breath test, stool antigen, serology) | * invasive (CLO test, histology, culture)