Peptic Ulcers Flashcards
What is the definition of a peptic ulcer?
A defect in gastric or duodenal mucosa with a diameter of at least .5cm and depth that penetrates through the muscularis mucosae
What is the definition of as gastric ulcer?
A peptic ulcer of the gastric mucosa, typically located along the lesser curvature in the transitional portion between corpus and antrum
What is the definition of a duodenal ulcer?
A peptic ulcer of the duodenal mucosa, usually located on the anterior or posterior wall of the duodenal bulb
What is the median age for developing a peptic ulcer?
18-30 years of age
What are the 2 most common causes of peptic ulcer disease?
Helicobacter pylori
Chronic NSAID use
How many cases of duodenal and gastric ulcers is H pylori associated with?
Duodenal - 40-70%
Gastric - 25-50%
What are the associated risk factors for peptic ulcer disease?
Smoking
Heavy alcohol use
Glucocorticoids
Caffeine
Diet
Anxietysgtress
PTSD
Genetic factors
What are some rare causes of PUD?
Acid hypersecretory state (gastrinoma for example)
Non NSAID medication eg acetaminophen, chemo
Infections eg EBV, CMV
Radiation
Illicit drug use eg cocaine
Systemic inflammatory disease eg chrons disease
What is gastric juice composed of?
HCL
Peposinogen
Intrinsic factor
Mucus
What prevents the gastric juice from damaging the stomach lining?
Secretion of mucus and HCO3
What can cause the ulcer formation?
When either the protective mechanisms are disrupted and or excessive acids or pepsin are secreted
What is the function of the parietal cells?
Secrete HCl and intrinsic factor
What stimulates the parietal cells?
Acetylcholine, histamine and gastrin
What inhibits parietal cells?
Prostaglandins
Somatostatin
What is the function of the mucosal cells?
Secrete protective mucus
What stimulates the mucosal cells?
Acetylcholine, prostaglandin (which inhibits HCl production) and Secretin
What is the purpose of chief cells?
Secrete pepsinogen
What stimulates the chief cells
Acetylcholine, gastric, secretin and vasoactive intestinal polypeptide
How does H pylori infection cause a gastric ulcer formation?
Hpylori secretes urease -> conversion of urea to Ammonia -> alkalinisation of acidic environment -> survival of bacteria in the gastric lumen. Bacterial colonisation and attachment to epithelial cells -> release of cytotoxins -> disruption of the mucosal barrier and damage to underlying cells
How does H pylori infection cause a duodenal ulcer formation?
Hpylori inhibits somatostatin secretion -> increased gastrin secretion -> increased acid production ->? Excess acid delivery to duodenum. Direct spread of Hpylori to duodenum -> Inhibition of duodenal HCO3 secretion -> acidification and insufficient neutralisation off duodenal contents
How do NSAID’s lead to peptic ulcer formation? (Pathophysiology)
Inhibits COX1 and COX2 -> decrease in prostaglandin production -> erosion of the gastric mucosa. Decrease mucosal blood flow. Inhibit mucosal cell proliferation.
How does acid hypersecretioon lead to peptic ulcer formation? (Pathophysiology)
Acid hypersecretion and increased gastrin production -> increased acid secretion and parietal cell mass -> delivery of excessive acid to the duodenum
Clinical features of peptic ulcer?
Up to 70% asymptomatic (more common in those who are due to NSAID use)
Epigastric abdominal pain - gnawing or burning in nature. Related to meal intake depending on location of ulcer
Belching
Indigestion
GER
Nausea and or vomiting
Bloating/abdominal fullness
Which clinical features are common in gastric and peptic ulcer? §
Dyspepsia - postprandial heaviness, early satiety, gnawing aching burning epigastric pain
Pain relief with antacids
Potential signs of internal bleeding eg anemia, hematemesis
Stool sample p=positive for occult blood
What are the differences in clinical features of gastric and duodenal ulcer?
Gastric - pain increases shortly after eating -> weight loss. Nocturnal pain less common
Duodenal - pain is relieved with foods intake -> weight gain. Pain increases after 2-5 hours of food ingestion. Nocturnal pain more common
What is a subtype of a peptic ulcer?
Stress ulcer
What is a stress ulcer associated with?
Erosive gastritis
What is the initial diagnosis approach for peptic ulcer?
Look for underlying cause eg NSAID’s.
CBC and BMP (basic metabolic panel) if suspicion for occult bleeding
What does a basic metabolic panel check?
Serum concentrations of -
Sodium
Potassium
Chloride
Bicarbonate
Urea nitrogen
Creatinine
Glucose
What is the diagnosis approach for patients <60 and without red flags for dyspepsia
Begin with non invasive testing for H pylori infection - urea breath test and stool antigen test
What is the diagnosis approach for patients >60/45 years with high gastric cancer prevalence, patients with red flags for dyspepsia and patients unresponsive to empiric medical therapy eg hpylori eradication therapy
Refer directly for esopaghogastroduiodenoscopy
What is Ruthie most accurate test to confirm peptic ulcer diagnosis?
Esophagogastroduodenoscopy
What are the other purposes of an EGD?
Malignancy screening - to differentiate between PUD and gastric cancer
Invasive hpylori testing
Hemostasis treatment
What are the differences between benign and malignant gastroduodenal ulcers?
(Look at picture in gallery)
What are the objectives of treatment of a peptic ulcer?
Removing symptoms
Healing the ulcerous cratere
Preventing reoccurrence
Preventing complications
Treatment of complications
What are the treatments for peptic ulcer?
Dietary management - Quit smoking and alcohol. Stoop NSAID us. 8 hours of sleep and small regular meals
What is the medical treatment of Peptic ulcer?
Duodenal ulcer and Hpylori - eradicate HP and antisecretory drugs
Duodenal ulcer and HP and NSAID - eradicate HP and antisecretory drugs and prostaglandins
DU and NSAID - antisecretory drugs and prostaglandins
Which antibiotics are used for the treatment of HP?
Amoxicillin 500mg x4/day
Clarithromycin 500-1500mg/day
Tetracycline 500mg x4/day
Metronidazole 2500mg x4/day
What are the antisecretory drugs used?
PPI’s - omeprazole 40mg/dauy
Pantoprazole 40mg/day
Rabeprazole 40mg/day
Lansoprazole 40mg/day
What are some Histamine receptor blocking drugs?
Ranitidine 150mg x2/day
Famotidine 20mg x2/day
Nizatidine 150mg x2/day
What is the modified Johnson classification of peptic ulcers?
Type 1 - ulcer along body of stomach, most often along lesser curvature at inciusra angularis along locus minoris resistantiae
Type 2 - ulcer in body in combination with duodenal ulcers. Associated with acid hypersecretion
Type 3 - in pyloric channel within 3cm of pylorus. Associated with acid hypersecretion
Type 4 - proximal gastroesophageal ulcer
Type 5 - can occur throughout stomach. Associated with chronic NSAID use eg aspirin
