Peptic ulcer/ gastritis

Question 1

What is peptic ulcer disease/ gastritis?

Answer 1

1. PUD ⇒ Ulceration of areas of the GI tract (deep break into the submucosa) due to exposure to gastric acid and pepsin
   - Peptic Ulcers → most commonly Gastric (stomach) & Duodenal (duodenal more common)
2. Gastritis ⇒ histological presence of mucosal inflammation (stomach becomes inflamed.)

Question 2

What are some causes of peptic ulcer disease and gastritis?

Answer 2

Caused by an imbalance between the damaging action of acid and pepsin and the mucosal protective mechanisms
1. COMMON CAUSES of peptic ulcer disease and gastritis:
- Helicobacter pylori
- NSAIDs, steroids, potassium supplements, SSRIs, and crack cocaine
- Alcohol
- Bisphosphonates damage the mucosal lining 
- Smoking slows mucosal healing 
2. RARE cause: Zollinger-Ellison syndrome (a condition in which a gastrin-secreting tumour or hyperplasia of the islet cells in the pancreas cause overproduction of gastric acid, resulting in recurrent peptic ulcers)

Question 3

Summarise the epidemiology of peptic ulcer disease and gastritis

Answer 3

COMMON
Annual incidence: 1-4/1000
More common in males
Mean age:
Duodenal ulcer: 30s
Gastric ulcers: 50s
Helicobacter pylori is usually acquired in childhood and prevalence is roughly equal to age in years

Question 4

What are the presenting symptoms of PUD/ gastritis?

Answer 4

1. Epigastric pain: often describes as ‘gnawing’ (DYSPEPSIA = EPIGASTRIC PAIN)
   - Relieved by antacids
2. Symptoms have a variable relationship to food intake:
   a. Gastric - pain is worse soon after eating
   b. Duodenal - pain is worse several hours after eating
3. Patients may present with complications e.g. haematemesis, melaena
4. Gastritis ⇒ nausea, vomiting & loss of appetite (leading to weight loss)

Question 5

What are the “alarm symptoms” of PUD/ gastritis?

Answer 5

ALARM Symptoms
1. Anaemia
2. Loss of weight
3. Anorexia
4. Recent onset
5. Melaena/haematemesis
6. Swallowing difficulty

Question 6

What investigations are used to diagnose/ monitor PUD/ gastritis?

Answer 6

1. Upper GI Endoscopy → Gold standard diagnostic test for PUD. Will reveal ulcerations and perform biopsies for H pylori also. Immediately refer any patient who presents with dyspepsia together with acute GI bleeding.
2. Test for helicobacter pylori → carbon-13 urea breath test or stool antigen test
   - Urea Breath Test ⇒ only test recommended for H. pylori post-eradication therapy
3. Erect CXR → may demonstrate pneumoperitoneum (free air in abdomen), suggesting perforated dudoenal ulcer
   - Dome Sign ⇒ perforated gastric ulcer
4. Raised Urea = upper GI bleed
   - Faecal Occult Blood Test → may be positive if bleeding
   - FBC → order only if patient seems clinically anaemic or has evidence of GI bleeding
   (If H.pylori positive, and symptoms don’t improve upon triple therapy, then endoscopy is needed)

Question 7

How is PUD/ gastritis managed?

Answer 7

1. Lifestyle → reduce smoking and alcohol intake
2. Medical (H.Pylori +ve) → triple therapy (PPI (Omeprazole) + Amoxicillin + Clarithromycin → if penicillin allergy then Metranidazole for amoxicilin)
   - 1 week course, taken twice daily
3. Medical (H.Pylori -ve) → stop drug causing ulcer (ie. NSAID) and offer 4-8 weeks of full dose PPI Therapy (Omeprazole 20mg)
   - For gastric ulcers, repeat endoscopy 6-8 weeks later to ensure ulcer healing and rule out malignancy. For duodenal ulcers, repeat test (urea breath test) for h.pylori 6-8 weeks later is usually sufficient. 
   - 4. Complicated peptic ulcer disease requires urgent surgical intervention with OGD for underunning of ulcers and haemostasis (laparotomy)

Question 8

What signs of PUD/ gastritis can be found on physical examination?

Answer 8

• There may be NO physical findings
• Epigastric tenderness
• Signs of complications e.g. anaemia

Question 9

Identify the possible complications of peptic ulcer disease and gastritis

Answer 9

Rate of major complication = 1 % per year
Major complications:
- Haemorrhage (haematemesis, melaena, iron-deficiency anaemia)
- Perforation
- Obstruction/pyloric stenosis (due to scarring, penetration, pancreatitis)

Question 10

Summarise the prognosis for patients with peptic ulcer disease and gastritis

Answer 10

• Overall lifetime risk = 10%
• Outlook is generally good because peptic ulcers associated with H. pylori can be cured by eradication