Peptic Ulcers Flashcards
Where are peptic ulcers most commonly found?
The lesser curve and antrum of the stomach and the anterior first part of the duodenum.
What are the causes of peptic ulcers?
H. Pylori, NSAIDs, smoking, alcohol, Zollinger-Ellison syndrome.
How do NSAIDs cause peptic ulcers?
Inhibit COX enzyme.
How does H. Pylori cause peptic ulcers?
It uses its own urease enzyme to convert urea to ammonia. This lowers the pH which leads to a disordered feedback mechanism and depletion of somatostatin release from D cells which leads to excessive acid.
The bacteria also provoke a chronic inflammatory response.
What is H. Pylori and where is it found?
It is a spiral shaped gram negative bacteria.
It only colonises the gastric mucosa (if found in duodenum it is due to gastric metaplasia).
Mostly affects ANTRUM.
How does smoking cause peptic ulcers?
Depleted prostaglandin production leads to reduced blood flow to the mucosa, hence a lack of HCO3- ions delivered to buffer acid and subsequently reduces ability of the stomach to heal itself.
How does alcohol cause peptic ulcers?
It affects the mucosal repair mechanisms.
How does Zollinger-Ellison Syndrome cause peptic ulcers?
The gastrinoma tumour is found in the head of the pancreas. It releases large amounts of gastrin and hence the stomach produces large amounts of acid.
How do peptic ulcers present?
Epigastric pain, tiredness, haematemesis/malaena, vomiting (relieves pain) (vomiting plus distension suggests gastric outlet syndrome).
What is the difference in presentation between gastric and duodenal ulcers?
Gastric ulcers are worst just before or whilst eating due to pressure of food on ulcer.
Dudenal ulcers are worse at night when hungry - acid produced is washed into duodenum with no buffering from food.
What investigations are performed when a peptic ulcer is suspected?
Gastroscopy, barium meal, urease breath test, erect CXR to check for perforations.
What are the possible complications of peptic ulcers?
Acute haemorrhage if ulcer comes across a vessel:
- Posterior duodenal = gastroduodenal artery.
- Peptic = left gastric artery.
Iron deficiency anaemia.
Perforation can lead to peritonitis.
Gastric outlet obstruction.
What is the management for peptic ulcers?
MEDICAL: Triple therapy eradication of H. Pylori - PPI, METRONIDAZOLE/AMOXICILLIN, CLARITHROMYCIN.
SURGICAL: Indicated either in emergencies if perforation or bleeding needs correcting or if failure to respond to medical treatment then partial gastrectomies are considered.
What is the emergency management of a bleeding ulcer?
Fluid resus, erect CXR, IV PPI, potentially blood transfusion and consider surgery.
What is the emergency management of a perforation?
Fluid resus, IV PPI, surgical omental patch closure.
