Peptic Ulcers Flashcards
Helicobacter pylori is a
Gram-negative bacteria
Helicobacter pylori Associations
peptic ulcer disease
gastric cancer
B cell lymphoma of MALT tissue
atrophic gastritis
H pylori seen in ?% of duodenal ulcers, ?% of gastric ulcers
95% of duodenal ulcers, 75% of gastric ulcers
B cell lymphoma of MALT tissue - eradication of H pylori results causes regression in ?% of patients
eradication of H pylori results causes regression in 80% of patients
Helicobacter pylori mx
eradication may be achieved with a 7 day course of
a proton pump inhibitor + amoxicillin + (clarithromycin OR metronidazole)
Helicobacter pylori mx if penicillin allergic:
a proton pump inhibitor + metronidazole + clarithromycin
Peptic ulcer disease (uncomplicated) drug associations?
NSAIDs
SSRIs
corticosteroids
bisphosphonates
Peptic ulcer disease (uncomplicated) sx
epigastric pain
nausea
duodenal ulcers - epigastric pain when hungry, relieved by eating
gastric ulcers - epigastric pain worsened by eating
Peptic ulcer disease (uncomplicated) ix
Helicobacter pylori should be tested for
either a Urea breath test or stool antigen test should be used first-line
Peptic ulcer disease (uncomplicated) mx
if Helicobacter pylori is negative then proton pump inhibitors (PPIs) should be given until the ulcer is healed
if Helicobacter pylori is positive then eradication therapy should be given
The symptoms of perforation secondary to peptic ulcer disease typically develop slowly
false
suddenly
The symptoms of perforation secondary to peptic ulcer disease include?
epigastric pain, later becoming more generalised
patients may describe syncope
Peptic ulcer disease (perforation) plain x rays diagnostic
false
diagnosis is largely clinical, UptoDate recommend that plain x-rays are the first form of imaging to obtain
Peptic ulcer disease (perforation) An upright (‘erect’) chest x-ray shows
75% of patients with a perforated peptic ulcer will have free air under the diaphragm
Bleeding is the most common cause of peptic ulcer disease, account for around three-quarters of problems.
true
Which artery can be the source of a significant gastrointestinal bleed occurring as a complication of peptic ulcer disease.
The gastroduodenal artery can be the source of a significant gastrointestinal bleed occurring as a complication of peptic ulcer disease.
Peptic ulcer disease (acute bleeding) sx
haematemesis
melaena
hypotension, tachycardia
Peptic ulcer disease (acute bleeding) mx
ABC
IV proton pump inhibitor
first-line treatment is endoscopic intervention
if this fails - urgent interventional angiography with transarterial embolization or
surgery
Helicobacter pylori: tests
should not be performed within ? weeks of treatment with an antibacterial or within ? weeks of an antisecretory drug (e.g. a proton pump inhibitor)
should not be performed within 4 weeks of treatment with an antibacterial or within 2 weeks of an antisecretory drug (e.g. a proton pump inhibitor)
Helicobacter pylori: tests
urea breath test may be used to check for H. pylori eradication
true
Helicobacter pylori: tests
Rapid urease test (e.g. CLO test) describe
biopsy sample is mixed with urea and pH indicator
colour change if H pylori urease activity
Helicobacter pylori: tests
Serum antibody
remains positive after eradication
true
Helicobacter pylori: tests Gastric biopsy describe
provides histological evaluation alone, no culture
culture of this provide information on antibiotic sensitivity
Gastric cancer - Epidemiology
peak age = 70-80 years
more common in east than the West
more common in males, 2:1
Gastric cancer - Histology
signet ring cells
large vacuole of mucin which displaces the nucleus to one side.
Gastric cancer Higher numbers of signet ring cells are associated with a worse prognosis
true
Gastric cancer Associations
H. pylori infection blood group A: gAstric cAncer gastric adenomatous polyps pernicious anaemia smoking diet: salty, spicy, nitrates may be negatively associated with duodenal ulcer
Gastric cancer sx
dyspepsia
nausea and vomiting
anorexia and weight loss
dysphagia
Gastric cancer ix
diagnosis: endoscopy with biopsy
staging: endoscopic ultrasound has recently been shown to be superior to CT
Tumours of the gastro-oesophageal junction are classified as
Type 1 - True oesophageal cancers and may be associated with Barrett’s oesophagus.
Type 2 Carcinoma of the cardia, arising from cardiac type epithelium
or short segments with intestinal metaplasia at the oesophagogastric junction.
Type 3 Sub cardial cancers that spread across the junction. Involve similar nodal stations to gastric cancer.
Gastric cancer staging ix
CT scanning of the chest abdomen and pelvis is the routine first line staging investigation in most centres. Laparoscopy to identify occult peritoneal disease PET CT (particularly for junctional tumours)
Gastric cancer Treatment Most patients will receive chemotherapy either pre or post operatively.
true
Gastric cancer mx
Proximally sited disease greater than 5-10cm from the OG junction may be treated by sub total gastrectomy
Total gastrectomy if tumour is <5cm from OG junction
Gastric cancer mx
type 2 junctional tumours
oesophagogastrectomy is usual
Gastric cancer prognosis - Percentage 5 year survival
All RO resections 54% Early gastric cancer 91% Stage 1 87% Stage 2 65% Stage 3 18%
Zollinger-Ellison syndrome is
ondition characterised by excessive levels of gastrin, usually from a gastrin secreting tumour usually of the duodenum or pancreas
Zollinger-Ellison syndrome is associated with MEN IIB
false
Around 30% occur as part of MEN type I syndrome
Zollinger-Ellison syndrome features
multiple gastroduodenal ulcers
diarrhoea
malabsorption
Zollinger-Ellison syndrome diagnosis
fasting gastrin levels: the single best screen test
secretin stimulation test
Acute upper gastrointestinal bleeding
which scores to use and when?
use the Blatchford score at first assessment, and
the full Rockall score after endoscopy
Blatchford score looks at
Urea (mmol/l) Haemoglobin (g/l) Systolic blood pressure (mmHg) Pulse >=100/min = 1 Presentation with melaena = 1 Presentation with syncope = 2 Hepatic disease = 2 Cardiac failure = 2
Patients with a Blatchford score of 0 may be considered for early discharge.
true
Acute upper gastrointestinal bleeding if actively bleeding transfuse with?
platelet transfusion
Acute upper gastrointestinal bleeding if actively bleeding when to transfuse with FFP
fibrinogen level of less than 1 g/litre, or a prothrombin time (international normalised ratio) or activated partial thromboplastin time greater than 1.5 times normal
Acute upper gastrointestinal bleeding if actively bleeding when to transfuse with prothrombin complex concentrate?
patients who are taking warfarin and actively bleeding
Endoscopy
should be offered immediately after resuscitation in patients with a severe bleed
true
Within 24 hrs
Acute upper gastrointestinal bleeding
Management of non-variceal bleeding PPIs before endoscopy
false
NICE do not recommend the use of proton pump inhibitors (PPIs) before endoscopy to patients with suspected non-variceal
PPIs should be given to patients with non-variceal upper gastrointestinal bleeding and stigmata of recent haemorrhage shown at endoscopy
Acute upper gastrointestinal bleeding
Management of non-variceal bleeding
PPIs should be given to patients with non-variceal upper gastrointestinal bleeding and stigmata of recent haemorrhage shown at endoscopy
if further bleeding - repeat endoscopy, interventional radiology and surgery
Acute upper gastrointestinal bleeding Management of variceal bleeding at presentation
terlipressin and prophylactic antibiotics should be given to patients at presentation (i.e. before endoscopy)
Acute upper gastrointestinal bleeding Management of variceal bleeding
for patients with gastric varices
injections of N-butyl-2-cyanoacrylate for patients with gastric varices
transjugular intrahepatic portosystemic shunts (TIPS) should be offered if bleeding from varices is not controlled with the above measures
Acute upper gastrointestinal bleeding Management of variceal bleeding
for oesophageal varices
band ligation should be used for oesophageal varices
transjugular intrahepatic portosystemic shunts (TIPS) should be offered if bleeding from varices is not controlled with the above measures
