Peptic ulcer disease - Upper GI

Question 1

What are the causes of acute + chronic peptic ulcers?

Answer 1

Question 2

In what % of patients does a peptic ulcer perforate?

Answer 2

2%

Question 3

What proportion of ulcer deaths are due to rupture?

Answer 3

• 2/3

BUT pain is the first clinical sign seen, rupture is the last

Question 4

What is the clinical presentation of perforated peptic ulcer?

Answer 4

• Epigastric pain
• acute = acute pain of short duration BUT also previous similar episodes with alternating periods of relief

Question 5

What is peptic ulcer disease?

Answer 5

A break in the mucosal lining of the stomach or duodenum more than 5 mm in diameter, with depth to the submucosa -

chronic, upper abdominal pain related to eating a meal (dyspepsia).

Peptic ulcers result from an imbalance between:

• factors promoting mucosal damage (gastric acid, pepsin, Helicobacter pylori infection, non-steroidal anti-inflammatory drug use) AND
• those mechanisms promoting gastroduodenal defense (prostaglandins, mucus, bicarbonate, mucosal blood flow).

Question 6

What is the name for ulcers smaller than peptic ulcers (5mm) or without obvious depth?

Answer 6

erosions

Question 7

What is the aetiology of peptic ulcer disease?

Answer 7

most common causes:

• Use of NSAIDs
• Helicobacter pylori infection
  
  • gram negative

There is some synergy between these two major causes

Rarer causes

• gastric ischaemia (responsible for the ‘stress ulcers’ that can occur in patients with multiple organ failure in intensive care units)
• Zollinger-Ellison syndrome (a syndrome of gastric acid hypersecretion caused by a gastrin secreting neuro-endocrine tumour)
• certain medications (e.g., potassium chloride, bisphosphonates)
• infections (cytomegalovirus in patients with HIV, occasionally herpes simplex virus)
• Crohn’s disease

Question 8

How are peptic ulcers classified?

Answer 8

based on anatomical location

• gastric
• duodenal

Question 9

Name the risk factors for peptic ulcer disease

Answer 9

Question 10

Summarise the epidemiology of peptic ulcer disease

Answer 10

Accurate estimates require endoscopic studies because symptoms are insensitive and non-specific indicators of peptic ulcer

• annual incidence of 0.10% to 0.19% for physician-diagnosed peptic ulcer disease and a 1-year prevalence of 0.12% to 1.50%.
• the prevalence of gastric ulcer varies significantly worldwide; 4.1 % in Sweden and 6.1% in China
• increases with age - peak in the fifth to seventh decades and duodenal ulcers 10 to 20 years earlier
• both sexes equally affected

The epidemiology of peptic ulcer disease largely reflects the epidemiology of the two major aetiologic factors

1. Helicobacter pylori infection
2. use of non-steroidal anti-inflammatory drugs (NSAIDs).

In the developed world, H pylori incidence has been slowly declining over the past 50 years and NSAID use has increased.

Most studies report that peptic ulcers are decreasing in prevalence over time. Nevertheless they remain a problem, especially in the developing world where H pylori infection is highly prevalent.

Question 11

What are the presenting symptoms of peptic ulcer disease?

Answer 11

abdo pain

Question 12

What are some uncommon signs/symptoms of peptic ulcer disease?

Answer 12

Question 13

What are the signs of peptic ulcer disease O/E?

Answer 13

• some epigastric tenderness
• pointing sign
  
  • pt can show site of pain with one finger.
• usually none

Question 14

Name the primary investigations for ?peptic ulcer disease

Answer 14

fasting serum gastrin level

• Ordered if there are multiple duodenal ulcers (especially postbulbar) or in patient with ulcers and diarrhoea.
• Patient must be fasting and proton-pump inhibitor therapy stopped.
• Elevated levels in pernicious anaemia and other hypochlorhydric states results in low specificity.
• results: hypergastrinaemia in Zollinger-Ellison syndrome

Question 15

What are some secondary investigations for peptic ulcer disease?

Question 16

What are the goals of management of peptic ulcer disease?

Answer 16

1. treat complications (e.g., active bleeding)
2. eliminate the underlying cause whenever possible
3. relieve symptoms
4. heal ulcers

Question 17

Explain the management plan for peptic ulcer disease (active bleeding ulcer)

Answer 17

requires urgent evaluation

1st line

• Endoscopy
  
  • diagnostic + therapeutic (adrenaline/clip)
• + IV PPI
  
  • reduces rebleeding

​NSAIDs including aspirin, should be ceased before treatment

presence of Helicobacter pylori should be assessed​ (post-intervention)

2nd line

• surgery or embolisation via interventional radiology

Question 18

Explain the management plan for peptic ulcer disease (no active bleeding)

Answer 18

H2 antagonists are less effective than proton-pump inhibitors but induce healing in the majority of patients.

Sucralfate has similar ulcer healing rates to H2 antagonists. However, the frequent dosing schedule and large tablet size may impact upon adherence; therefore this drug is rarely recommended.

Misoprostol is an option for the prevention of NSAID-induced gastric ulcers in patients who need to continue NSAID therapy.[35]

Question 19

Explain the management plan for peptic ulcer disease (Recurrence or refractory ulcers)

Answer 19

Question 20

Name some possible complications of peptic ulcer disease

Answer 20

• penetration
  
  • Occurs when chronic ulcer penetrates the entire thickness of the stomach or duodenal wall, into an adjacent organ such as the pancreas, but without free perforation into the peritoneal cavity
• gastric outlet obstruction
  
  • ​from chronic pyloric stenosis may occur as pyloric channel ulcers heal with scarring and oedema.
• gastroduodenal bleeding
  
  • It occurs when an ulcer erodes into the wall of a gastroduodenal blood vessel.
  • ​Peptic ulcer disease is the cause of over 20% of all acute upper GI bleeding
• perforation - less common
  
  • Caused by erosion of the ulcer through the wall of the stomach or duodenum into the peritoneal cavity
  • Most perforations occur in older patients, in patients taking NSAIDs and in patients with ulcers in the duodenum or gastric antrum.
  • Usual presentation is with shock and peritonitis.

Question 21

How would a gastric outlet obstruction present?

How would it be managed?

Answer 21

May present with nausea, vomiting, and weight loss. A succussion splash may be elicited on examination.

Management is aimed at treating the cause of the ulcer. High-dose proton-pump inhibitors are also used in the management of this condition. Endoscopic dilation is often helpful, with surgery reserved for refractory patients

Question 22

Summarise the prognosis of peptic ulcer disease

Answer 22

With proton-pump inhibitor (PPI) therapy, duodenal ulcers typically heal within 4 weeks and gastric ulcers within 8 weeks.

For patients with peptic ulcers caused by Helicobacter pylori, the prognosis post H pylori eradication is good: risk of recurrence of duodenal ulcer is approximately 20%, risk of recurrence of gastric ulcer approximately 30%.[36]H pylori eradication is also beneficial in those with complicated ulcer disease.

For ulcers associated with use of NSAIDs, discontinuing the NSAID (and eradicating H pylori if present) will lead to a low rate of ulcer recurrence. In patients who continue using NSAIDs, ulcer recurrence is high, and thus coprescription of a PPI is advisable.