Peptic ulcer disease (PUD)

Question 1

1) What 2 ulcers make up PUD?
2) Which of these is the most common?

Answer 1

1) Duodenal and gastric ulcers
2) Duodenal (1:4)

Question 2

Pathology of PUD
1) What 2 mechanisms increases how prone the stomach and duodenum is to ulceration?
2) What are the 2 main causes of a breakdown of the protective layer of the stomach and duodenum?
3) Name 3 causes of increased acid production

Answer 2

1) Increased acid production and breakdown of the protective layer of the stomach and duodenum
2) H. Pylori infection and NSAIDs
3) Stress, alcohol, caffeine, smoking and spicy foods

Question 3

1) Which type of ulcer is often most severe?
2) Which type of ulcer improves after eating (with the other worsening)?
3) Around 90% of duodenal ulcers are caused by what?

Answer 3

1) Gastric
2) Duodenal
3) H. Pylori infection

Question 4

1) Name 2 risk factors for developing PUD
2) Name a risk factor for developing a gastric ulcer
3) Name a risk factor for developing a duodenal ulcer

Answer 4

1) NSAIDs, H. Pylori infection, smoking
2) Severe stress, delayed gastric emptying
3) SSRIs, increase in gastric acid secretion, increased gastric emptying

Question 5

Name 3 ways PUD may present

Answer 5

• Epigastric discomfort/pain/tenderness
• Nausea and vomiting
• Symptoms associated with dyspepsia (heartburn, abdominal distention and bloating)
• Haematemesis - “coffee ground” vomiting
• Melaena
• Iron deficiency anaemia
• Intolerance to fatty foods

Question 6

1) What should happen to patients that present with dyspepsia that are over 55 y.o. or have ALARMS signs?
2) What are the ALARMS signs?

Answer 6

1) Urgent endoscopy within 2 weeks to investigate cancer
2) Anaemia (iron def), Loss of weight, Anorexia, Recent onset or progressive symptoms, Melaena (or haematemesis), Swallowing difficulty

Question 7

1) How are peptic ulcers diagnosed?
2) What test is also done during this investigation, and for what?

Answer 7

1) Endoscopy
2) CLO test (rapid urease test) - H. Pylori

Question 8

1) If there’s no H. Pylori, what is the management?
2) Name 3 aspects of the lifestyle advice that would be given

Answer 8

1) 4-8 weeks of full dose PPI treatment and lifestyle advice or H2 antagonists
2) Stop smoking, cut down on alcohol, have more regular, smaller meals and eat 4 hours before bed, avoid acidic foods, coffee, fatty or spicy foods, encourage weight loss if obese,
avoid NSAIDs, steroids, bisphosphonates, potassium supplements, SSRIs and crack cocaine

Question 9

Name 3 complications of PUD

Answer 9

• Bleeding
• Perforation causing acute abdomen or peritonitis
• Malignancy
• Gastric obstruction due to scarring or a stricture

Question 10

1) What kind of bacteria is H. Pylori?
2) How does it cause damage to the stomach?
3) Apart from the rapid urease test, what other 2 tests can be done for H. Pylori?
4) How is H. Pylori eradicated?
5) What test is done to see if H.Pylori has been eradicated post therapy?

Answer 10

1) Gram negative aerobic bacteria
2) To avoid the acidic environment it forces its way into the gastric mucosa. The breaks it creates in the mucosa exposes the epithelial cells underneath to acid. It also produces ammonia which damages epithelial cells
3) Urea breath test and stool antigen test
4) PPI + amoxicillin and either clarithromycin or metronidazole
5) Urea breath test

Question 11

1) What is the key investigation in a perforated peptic ulcer, and what might it show?
2) A positive result would warrant further investigation with what?

Answer 11

1) Erect CXR - air under diaphragm - pneumoperitoneum
2) CT