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AIP: Gastrointestinal bleed > Peptic ulceration - H. pylori > Flashcards

Peptic ulceration - H. pylori Flashcards

1
Q

What is meant by the term ‘peptic ulcer’?

A

ulcer in the lower oesophagus, stomach or duodenum, in the jejunum after surgical anastomosis to the stomach or, rarely, ileum adjacent to Meckel’s diverticulum

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2
Q

What are 5 possible locations of peptic ulcers?

A
  1. Lower oesophagus
  2. Stomach
  3. Duodenum
  4. Jejunum after surgical anastomosis to stomach
  5. Ileum adjacent to Meckel’s diverticulum
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3
Q

What is the nature of peptic ulcers in the stomach or duodenum?

A

acute or chronic

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4
Q

Structurally, what is the difference between acute and chronic peptic ulcers?

A

both penetrate muscularis mucosae, but acute ulcer shows no evidence of fibrosis

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5
Q

How does an erosion differ structurall from a peptic ulcer?

A

erosions do not penetrate the muscularis mucosae

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6
Q

Why is the prevalence of peptic ulcer decreasing in many Western communities?

A

widespread use of H. pylori eradication therapy

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7
Q

Where are 90% of chronic gastric ulcers situated?

A

lesser curve within the antrum or at the junctino between body and antral mucosa

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8
Q

Where do chronic duodenal ulcers usually occur?

A

first part of duodenum; 50% on anterior wall

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9
Q

In what proportion of patients is there more than one peptic ulcer?

A

10-15% of patients

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10
Q

What proportion of a) duodenal ulcer and b) gastric ulcers are associated with H. pylori?

A

a) 90% b) 70%

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11
Q

What is responsible for the remaining 30% of gastric ulcers not accounted for by H. pylori?

A

NSAIDs

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12
Q

How is H. pylori spread?

A

acquired in childhood by person-to-person contact

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13
Q

What type of bacteria is H. pylori?

A

gram-negative and spiral, multiple flagella at one end

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14
Q

What type of mucosa does H. pylori colonise?

A

gastric type epithelium; only found in duodenum in association with patches of gastric metaplasia

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15
Q

How does H. pylori cause ulcers?

A

provokes local inflammatory response in the underlying epithelium, based on expression of genes cagA and vacA. CagA product injected into epithelial cells, interacting with cell-signalling pathways involved in replication and apoptosis

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16
Q

Whta are the 5 stages leading to duodenal ulceration?

A
  1. Depletion of antral D-cell somatostatin
  2. Increased gastrin release from G cell
  3. Increased acid secretion
  4. Increased acid load in duodenum leads to gastric metaplasia
  5. Further inflammation and eventual ulceration
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17
Q

What are 2 key environmental factors which contribute to the formation of peptic ulcers?

A
  1. NSAIDs
  2. Smoking
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18
Q

What is the most common presenting feature of peptic ulcer disease and what is the nature of this?

A

recurent abdominal pain - localisation to the epigastrium, relationship to food and episodic occurrence

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19
Q

What are the 3 key features of abdominal pain due to peptic ulcer?

A
  1. Localisation to epigastrium
  2. Relationship to food
  3. Episodic occurrence
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20
Q

What proportion of patients suffering with peptic ulcer experience occasional vomiiting?

A

40%

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21
Q

What is meant by a silent ulcer?

A

presenting for first time with anaemia from chronic undetected blood loss, abrupt haemtemesis or acute perforation

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22
Q

What is the preferred investigation to diagnose peptic ulcers?

A

endoscopy

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23
Q

What must always be done on endoscopy for suspected peptic ulcer and why?

A

biopsy and followed up to ensure healing - as can occasionally be malignant

24
Q

What are the 2 key investigations for a suspected, non-bleeding peptic ulcer?

A
  1. H. pylori
  2. Endoscopy
25
Q

Which 2 H. pylori tests are best and why?

A
  1. 13C Urea breath test
  2. Faecal antigen tests

accuracy, simplicity and non-invasiveness

26
Q

What are 2 key disadvantages of serology H. pylori tests?

A
  1. Lacks specificity
  2. Cannot differentiate current from past infection
27
Q

What is the relationship of duodenal vs gastric ulcers with food?

A
  • duodenal ulcers cause epigastric pain when hungry which is relieved by eating
  • epigastric pain worsened by eating in gastric ulcers
28
Q

What is the management of H. pylori associated peptic ulcer disease?

A

eradication therapy: PPI taken simultaneously with two antibiotics of amoxicillin, clarithromycin and metronidazole for at least 7 days

29
Q

How long does H. pylori eradication therapy last for?

A

7 days

30
Q

How frequently is H. pylori treatment successful?

A

80-90% of patients

31
Q

What are 6 common side effects of H. pylori eradication therapy?

A
  1. Diarrhoea
  2. Flushing and vomiting when taken with alcohol (metronidazole)
  3. Nausea, vomiting
  4. Abdominal cramps
  5. Headache
  6. Rash
32
Q

What are 10 indications for H. pylori eradication therapy?

A
  1. Peptic ulcer
  2. Extranodal marginal-zone lymphomas of MALT type
  3. Family history of gastric cancer
  4. Previous resection for gastric cancer
  5. H. pylori -positive dyspepsia
  6. Long-term NSAID or low-dose aspirin users
  7. Chronic (> 1 year) PPI users
  8. Unexplained vitamin B 12 deficiency if H pylor positive
  9. Idiopathic thrombocytopenic purpura
  10. Iron deficiency anaemia
33
Q

What are 2 indicatoins for emergency peptic ulcer surgery?

A
  1. Perforation
  2. Haemorrhage
34
Q

What are 3 indications for elective peptic ulcer surgery?

A
  1. Gastric outflow obstruction
  2. Persistent ulceration despite adequate medical therapy
  3. Recurrent ulcer following gastric surgery
35
Q

What are 4 risk factors for peptic ulcer disease?

A
  1. H. pylori
  2. Drugs: NSAIDs, SSRIs, corticosteroids, bisphosphonates
  3. Zollinger-Ellison
  4. Alcohol + smoking role
36
Q

What are 4 examples of drugs which increase the risk of peptic ulcer disease?

A
  1. NSAIDs
  2. SSRIs
  3. Corticosteroids
  4. Bisphosphonates
37
Q

What is Zollinger-Ellison syndrome?

A

rare cause of peptic ulcers characteised by excessive levels of gastrin, usually froma gastrin-secreting secreting tumour (will have high serum gastrin)

38
Q

Which artery can be the source of a significant gastrointestinal bleed occurring as a complication of peptic ulcer disease?

A

gastroduodenal artery

39
Q

What are 4 clinical features of acute bleeding secondary to peptic ulcer disease?

A
  1. Haematemesis
  2. Melaena
  3. Hypotension
  4. Tachycardia
40
Q

What is the approach to management of an acutely bleeding peptic ulcer? 4 key aspects

A
  1. ABC approach - 2 wide bore IV cannulas, give fluids - activate major haemorrhage protocol if needed + cross match 2 units of blood
  2. make nil by mouth
  3. urgent endoscopy + endoscopic treatment
  4. IV PPI after endoscopy if not suspected varices
41
Q

What are 2 further measures if endoscopic intervention is unsuccessful for acutely bleeding peptic ulcers?

A
  1. Urgent interventional angiography with transarterial embolisation
  2. Surgery
42
Q

What risk assessment scores can be used for acute bleeding and when?

A
  1. Blatchford score - at first assessment to determine whether to scope/when
  2. Rockall score - after endoscopy, predicts mortality
43
Q

What are 2 indications for fresh frozen plasma transfusion in acute upper GI bleeds?

A
  1. Fibrinogen <1g/L
  2. Prothrombin time (INR) or activated partial thromboplastic tine (APPT) >1.5x normal
44
Q

What should be given to patients who are taking warfarin and are actively bleeding?

A

prothrombin complex concentrate (vit K takes a few days to work)

45
Q

Within what time frame should endoscopy be performed in an acutely bleeding peptic ulcer?

A

within 24 hours

46
Q

When should IV PPI be given in a non-variceal upper GI haemorrhage?

A

not recommended before endoscopy

47
Q

What blood group is thought to be a risk factor for duodenal ulcers?

A

blood group O

48
Q

What is the management of H pylori negative peptic ulcer disease?

A

4-8 weeks of full dose PPI treatment (to heal ulcer) and lifestyle advice

49
Q

What are 7 pieces of lifestyle advice to give in H. pylori negative peptic ulcer disease?

A
  1. stop smoking
  2. cut down alcohol
  3. avoid NSAIDs, steroids, bisphosphonates, potassium supplements, SSRIs and crack cocaine
  4. avoid stress
  5. encourage weight loss if obese
  6. avoid acidic foods, coffee, fatty or spicy foods
  7. regular, smaller meals, 4 hours before bed
50
Q

What follow up of patients with peptic uclers should be performed?

A

repeat endoscopy 6-8 weeks after start of PPI treatment to ensure healing and rule out malignancy

51
Q

What are 4 endoscopic interventions for peptic ulcer disease?

A
  1. Adrenaline injection (dual therapy + :)
  2. Ulcer clipping
  3. Heater probe
  4. Haemospray (TC325)
52
Q

What surgical operation of choice is performed for a chronic non-healing gastric ulcer?

A

partial gastrectomy

53
Q

What surgical repair is indicated in an emergency for a bleeding peptic ulcer?

A

under running the ulcer for bleeding with sutures, or oversewing (patch repair) for perforation

54
Q

What are 7 complications of gastrectomy surgery for peptic ulcer?

A
  1. Dumping - rapid gastric emptying causing distension of proximal small bowel
  2. Chemical (bile reflux) gastropathy
  3. Diarrhoea and maldigestion
  4. Weith loss
  5. Anaemia
  6. Metabolic bone disease
  7. Gastric cancer
55
Q

What are 3 key complications of peptic ulcer disease?

A
  1. Perforation
  2. Bleeding (upper GI haemorrhage)
  3. Gastric outlet obstruction

AIP: Gastrointestinal bleed (11 decks)

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