Peptic Ulcers

Question 1

Peptic Ulcer

Pathophysiology

Causes

Answer 1

There is a protective layer in the stomach comprised of mucus and bicarbonate secreted by the stomach mucosa that protects it from stomach acid

This protective layer can be broken down by:

• Medications (e.g. steroids or NSAIDs)
• Helicobacter pylori

Zollinger Ellison syndrome
Cushing ulcer
Curlings ulcer

Increased acid can result from:

• Stress
• Alcohol
• Caffeine
• Smoking
• Spicy foods

Question 2

Duodenal Ulcer Clinical Features

Answer 2

Epigastric BURNING pain IMPROVED by eating

Nausea and vomiting

FEELING OF FULLNES or bloating or belching due to swelling of ulcer

Red flags: dysphagia, anaemia, weight loss

Question 3

Gastric Ulcer Clinical Features

Answer 3

Epigastric burning pain WORSENED by eating and worse before eating or at night Bloating Nausea vomiting Red flag sx

Question 4

Epidemiology

Answer 4

Duodenal ulcer is more common Gastric ulcers are more common in elderly

Question 5

Zollinger Ellison syndrome Features What is it Cause Pathology for ulcers

Answer 5

Multiple or refractory ulcers Gastrin secreting tumour of the pancreas As part of MEN1 or alone MOre gastrin causes gastric mucosa hypertrophy and increased acid production with causes ulcers of mucosa

Question 6

Cushing ulcer Pathology

Answer 6

Head injury and raised ICP stimulates vagus nucleus so more acid secreted Also cortisol is raised and intestinal barrier affected

Question 7

Curlings ulcer

Answer 7

Severe burns leading to reduced plasma volume Causing Ischaemia of gastric mucosa so cell necrosis and ulcers

Question 8

Investigations

Answer 8

Peptic ulcers are diagnosed by endoscopy

During endoscopy a rapid urease test (CLO test) can be performed to check for H. pylori

Biopsy should be considered during endoscopy to exclude malignancy as cancers can look similar to ulcers during the procedure.

Question 9

Management

Answer 9

Conservative: lifestyle changes (no hot and spicy food, stop smoking)

Medical:
- Simple antacids e.g. gaviscon

• PPI or H2RAs
• H pylori eradication: triple therapy of PPI + Clarithromycin + Metronidazole

(Surgery:

• Vagotomy to remove vagus nerve
• Antrectomy)

Endoscopy can be used to monitoring the ulcer to ensure it heals and to assess for further ulcers.

Question 10

Ulcer complications

Answer 10

Haemorrhage causing malena or iron deficient anaemia

Malignancy: mainly gastric ulcer going into gastric cancer

Perforation resulting in an “acute abdomen” and peritonitis. This requires urgent surgical repair (usually laparoscopic).

Scarring and strictures of the muscle and mucosa:

• This can lead to pyloric stenosis: a narrowing of the pylorus (the exit of the stomach) causing difficulty in emptying the stomach contents.

[Pyloric stenosis presents with upper abdominal pain, distention, nausea and vomiting, particularly after eating.]