Peptic ulcers

Question 1

what are the risk factors for ulcers? (5)

Answer 1

smoking, alcohol consumption
chronic gastritis caused by H. Pylori infection (duodenal and gastric ulcers)
long term use of NSAIDs (risk is 5 times higher)
long term use of NSAIDs and glucorticoids
Zollinger Ellison Syndrome

Question 2

how do you classify gastric ulcer?

Answer 2

lesser curvature and gastric antrum

Question 3

what are the risk factors for gastric ulcers? (6)

Answer 3

H.pylori, 
smoking, 
NSAIDs, 
reflux of duodenal contents, 
delayed gastric emptying, 
stress, 
e.g. neurosurgery or burns, (Cushing’s or Curling’s ulcers). 
Symptoms:

Question 4

what are the symptoms of gastric ulcers?

Answer 4

asymptomatic or epigastric pain relieved by antacids +- weight loss

Question 5

what tests would you do?

Answer 5

• Upper GI endoscopy to exclude malignancy multiple biopsies from ulcer rim and base (histology, H.Pylori)
• Repeat endoscopy after 6-8 weeks to confirm healing and exclude malignancy.

Question 6

what are features of duodenal ulcers?

Answer 6

Duodenal bulb, hypertrophy of Brunner glands. 4 fold commoner than GU.

Question 7

what are major risk factors for duodenal ulcers?

Answer 7

H.Pylori, drugs (NSAIDs, steroids, SSRIs).

Question 8

what are minor risk factors for duodenal ulcers?

Answer 8

Increased gastric secretion, increased gastric emptying (decreased duodenal pH), blood group 0, smoking.

Question 9

what are the symptoms and signs of duodenal ulcers?

Answer 9

Asymptomatic or epigastric pain (relieved by antacids) +- weight loss.

Signs:

Epigastric tenderness.

Question 10

how do you diagnose duodenal ulcers?

Answer 10

Upper gI endoscopy. Test for H.pylori. measure gastrin concentrations when off PPIs if Zollinger-Ellison syndrome is suspected.

Question 11

what are the differential diagnosies for duodenal ulcers?

Answer 11

non-ulcer dyspepsia, 
duodenal chronics, 
TB,
lymphoma, 
pancreatic cancer.

Question 12

what is erosive gastritis?

Answer 12

acute mucosal inflammation of the stomach that does not extend beyond the muscular is mucosae.

Question 13

what is the pathophysiology of ulcers?

Answer 13

• H pylori gastritis: increased acid secretion, decreased protective factors/mucus production
• NSAIDs: decreased protective prostaglandins

Question 14

what are the general symptoms of ulcers?

Answer 14

epigastric pain often related to hunger, specific times of the day or food.
fullness after meals.
tender epigastrium
retrosternal pain (heart burn)
beware alarm symptoms
dyspepsia
pain releif with antacids
potential sign of internal bleeding (melena, hamatesis)
stool sample positive fro occult blood
hunger pain -> relieved after eating -> weight gain
nocturnal pain

Question 15

what are symptoms of gastric ulcers?

Answer 15

pain increases shortly after eating -> weight loss

nocturnal pain in around 30-40% pateints

Question 16

what are symptoms of duodenal ulcers?

Answer 16

pain increases 2-5 hours after eating.

Question 17

what is the problem with taking NSAIDs?

Answer 17

Taking NSAIDs can often mask PUD symptoms until complications such as haemorrhage and perforation can occur.

Question 18

what do you do in H. Pylori

Answer 18

If 55 years old or older:

Test and treat for h.pylori.
If positive give appropriate PPI and 2 antibiotic combination, e.g. lansoprazole.

Refer for urgent endoscopy all with dysphagia, as well as those over 55 with alarm symptoms or with treatment-refractory dyspepsia.

Question 19

what is the treatment for H. Pylori?

Answer 19

Lifestyle:

• Decrease alcohol
• Tobacco

H. Pylori eradication:

• Triple therapy is 80-85% effective at eradication

Drugs to reduce acid:

PPIs are effective, e.g. lansoprazole or 8 GU weeks. H2 blockers have a place (ranitidine 300mg each night PO for 8 weeks

Question 20

how do you treat drug induced ulcres>

Answer 20

Drug induced ulcers:

Stop drugs if possible. PPIs may be best for treating and preventing GI ulcers and bleeding patients on NSAID or antiplatelet drugs.
Misoprostol is an alternative with different SE.
If symptoms persist, re-endoscope, retest for Pylori, and reconsider differential diagnoses (e.g. gallstones)

Question 21

what are the complications of uclers?

Answer 21

• Bleeding
• Perforation
• Malignancy
• Decreased gastric outflow.