Peptic Ulcers

Question 1

What is a peptic ulcer?

Answer 1

A break in the mucosal lining of the lower oesophagus, stomach or duodenum more than 5mm in diameter, with debts to the submucosa.

Question 2

What is the underlying pathology of a peptic ulcer?

Answer 2

Imbalance between factors promoting mucosal damage and those mechanisms promoting gastroduodenal defence.

Question 3

What are the factors promoting mucosal damage?

Answer 3

Gastric acid, pepsin, H. pylori, NSAIDs.

Question 4

What are the factors promoting gastro duodenal defence?

Answer 4

Bicarbonate, prostaglandins, mucus, mucosal blood flow.

Question 5

Which is more common duodenal ulcers or gastric ulcers and where are they found?

Answer 5

1. Duodenal ulcers of 4 times more common than gastric ulcers
2. Gastric antrum or proximal duodenum

Question 6

What are the causes of peptic ulcers?

Answer 6

1. H. pylori (80-90%)
2. Drugs (aspirin, NSAIDs, steroids)
3. Smoking, alcohol, stress
4. Zollinger Ellison syndrome

Question 7

What is this a presentation of?

Epigastric pain related to hunger or specific foods, heartburn, signs of bleeding, tender epigastrium.

Answer 7

Peptic ulcer

Question 8

What is the key difference between the presentation of duodenal and gastric ulcers?

Answer 8

1. Duodenal - pain gets better when eating

2. Gastric - pain gets worse when eating

Question 9

What is the pathophysiology of peptic ulcer?

Answer 9

Chronic inflammation:

1. Persistent tissue injury and destruction at the surface
2. Inflammatory response to limit the damage
3. Attempts to organise and heal by fibrosis

Question 10

What is helicobacter pylori, what is its route of transmission, what is its pathophysiology, and what is it a risk factor for?

Answer 10

1. Gram negative bacteria
2. Oral-oral or faecal-oral
3. Colonises mucus on top of mucosal surface, synthesizes and releases urease (forms ammonia from urea), neutralises gastric acid and improves survival of bacteria.
4. Gastric cancer and MALT lymphoma

Question 11

Which medication should you switch two weeks prior to testing for H. pylori?

Answer 11

PPI should be switched to H2 antagonist

Question 12

What are the non-invasive first-line investigations for H. pylori?

Answer 12

1. 13C breath test (urea breath test)
2. Stool antigen
3. Serology (IgG)

Question 13

What are the invasive tests for H. pylori?

Answer 13

1. CLO test

2. Histology

Question 14

What is the triple therapy for H. pylori?

Answer 14

1. Omeprazole 20mg BD
2. Clarithromycin 500mcg BD
3. Amoxicillin 1g BD

Question 15

When and how should you check for the eradication of H. pylori after treatment?

Answer 15

1. 1 month after the end of therapy

2. Urea breath test

Question 16

What are the complications of a H. pylori infection?

Answer 16

1. Bleeding - acute (melaena/haematemesis), chronic (anaemia)
2. Perforation - peritonitis
3. Stricture formation - fibrosis healing, obstruction
4. Malignancy - rare