PEPTIC ULCERS

Question 1

What is a peptic ulcer?

Answer 1

A peptic ulcer in an open sore of the mucosa of the stomach or duodenum.

Question 2

Where in the abdomen do people with peptic ulcers most often experience pain?

Answer 2

Epigastric region

Question 3

When do patients with a gastric ulcer experience pain?

Answer 3

Shortly after eating

Question 4

When do patients with a duodenal ulcer experience pain?

Answer 4

May start a couple of hours after eating and will recede after eating food.

Question 5

What are the complications of a peptic ulcer?

Answer 5

Pain
Vomiting dark brown blood (coffee ground)
Haemetemesis
Melena
Anaemia
Perforation of stomach wall 
Peritonitis --> Sepsis
Increased risk of malignancy

Question 6

What are the factors that are normally well balanced which contribute towards the development of a peptic ulcer when they fall out of balance?

Answer 6

Gastric acid and pepsin secretion

Mucus defense barrier

Question 7

What are the risk factors for developing a peptic ulcer?

Answer 7

H. pylori infection (70% of gastric ulcers)
NSAIDs, such as aspirin.
Zollinger-Ellison syndrome (hypergastrinaemia)
Smoking
Alcohol
Gastric hyperactivity
Duodenal-gastric reflex

Question 8

How do NSAIDs lead to the development of a peptic ulcer?

Answer 8

Inhibit prostaglandin production through inhibition of cyclo-oxygenase.

This prevents production of prostaglanding H2 (from arachodinic acid) which is a precursor for (among others) prostaglandin E2.

Prostaglandin E2 is an inhibitor of H2 mediated gastric acid secretion.

Question 9

How does H. pylori infection lead to the development of a peptic ulcer?

Answer 9

The H pyloria bacteria go through the mucus lining to penetrate the epithelial lining.

The ammonia produced by the bacteria to regulate pH is toxic to the epithelial cells. The damage and the ensuing inflammation allows the stomach acid and the pepsin to overwhelm the protective mechanisms and the ulcer develops.

Question 10

How would someone with a peptic ulcer typically present?

Answer 10

Dull, gnawing ache epigastric pain
Pain after eating (gastric ulcer)
Pain 2 hours after eating, that is relieved by further eating (duodenal ulcer)

Question 11

How do we diagnose a patient with peptic ulcers?

Answer 11

History
Examination

Endoscopy with biopsy
Barium meal

Question 12

What is the more invasive way in which we diagnose whether the patient’s peptic ulcer was a result of H. pylori infection?

Answer 12

CLO test (Rapid urease test):
Biopsy is taken from the antrum of the stomach and placed into a medium containing urea and an indicator such as phenol red. An increase in pH as a result of production of ammonia by H. pylori urease changes colour from yellow to red. 

Histology of biopsy

Culture from biopsy also used

Question 13

In which patients might you want to take a biopsy from the fundus or body of the stomach, when carrying out the CLO test (assessing the presence of H. pylori)?

Answer 13

Patients on therapy with proton pump inhibitors.

Evidence to suggest that the H. pylori moves proximal in these patients.

Question 14

What is the less invasive way in which we diagnose whether the patient’s peptic ulcer was a result of H. pylori infection?

Answer 14

Urea breath test:
Patient drinks a solution enriched with 13C-labelled urea.
The amounts of 13C-CO2 product from the urease is measured in the breath.

Question 15

What are the treatment options for someone diagnosed with a peptic ulcer?

Answer 15

Ulcers associated with H. pylori:
Antibiotics (amoxicillin, clarithromycin and metronidazole)
PPI

Ulcers not associated with H. pylori:
Proton pump inhibitors (omeprazole)
H2 blockers (renitidine)
Discourage smoking

Question 16

Where are most peptic ulcers founds?

Answer 16

75% are duodenal

Question 17

What are the factors that contribute to the maintenance of the mucosal defense barrier which prevents the formation of peptic ulcers?

Answer 17

Surface mucus secretion
Bicarbonate secretion into mucus
Mucosal blood flow
Apical surface membrane transport
Epithelial regenerative capacity
Elaboration of prostaglandins

Question 18

What type of bacteria is H. pylori?

Answer 18

Spiral shaped gram negative

Question 19

What are the antibiotics used to eradicate H. pylori in someone with acute gastritis?

Answer 19

Combination of amoxicillin, clarithromycin and metronidazole

2 times a day for 7 days

Question 20

What might you be able to do for a patient with peptic ulcers where the taking of NSAIDs is still clinically desirable (eg severe rheumatoid arthritis)?

Answer 20

Use lowest dose of NSAID

Misoprostol is a synthetic prostaglandin analogue with mucosal protective properties

Concomitant use of PPI and NSAIDs

Switch NSAID to cox-2 inhibitor (increased risk of adverse cardiovascular side effects)

Question 21

What blood group has a 40% increase in risk of developing a duodenal ulcer compared to the general population?

Answer 21

Blood group O