Peptic Ulcers & dyspepsia

Question 1

What is a peptic ulcer?

Answer 1

An ulcer of the mucosa in or adjacent to an acid bearing area.

Mostly stomach or proximal duodenum

Question 2

Which are more common: gastric or duodenal ulcers?

Answer 2

Duodenal

Question 3

What causes peptic ulcers?

Answer 3

Helicobacter pylori infection

NSAIDs

Diseases like Sarcoidosis, Crohn’s

Increased gastric acid secretion

Smoking

Stress

Mucosal ischaemia

Question 4

What are the clinical features of peptic ulcers?

Answer 4

Epigastric pain, increases in hunger, after specific foods, certain times of day (at night)

Nausea
Heartburn
Flatulence

Occasionally: painless with haemorrhage

Question 5

When you see a patient with peptic ulcers or dyspepsia, what are the red flag symptoms to look for?

Answer 5

ALARMS

Anaemia
Loss of weight
Anorexia
Recent onset
Melaena / haematemesis
Swallowing difficulty

Question 6

Investigation of peptic ulcers.

Answer 6

Test for H. pylori infection in under 55s

Endoscopy and biopsy: to distinguish between benign an malignant ulcer

Question 7

What are the tests for H. pylori?

Answer 7

Breath test: look for CO2 that the bacteria produce

Stool antigen test

Question 8

What is likely to be the cause of epigastric pain that is worst straight after eating?

Answer 8

Gastritis
GORD
Gastric cancer

Question 9

What is likely to be the cause of epigastric pain that is worst a little after eating and is relieved by drinking cool, mild fluids?

Answer 9

Duodenal ulcer

Question 10

Management of a peptic ulcer that is not suspected to be cancer.

Answer 10

Lifestyle changes: weight loss, drink less alcohol

PPIs

Stop NSAIDs

Give a course of antibiotics if H. pylori is present

Question 11

What complications can arise from peptic ulcers?

Answer 11

Ulcer goes through artery: Haemorrhage

Ulcer goes through wall: Perforation, which can lead to peritonitis + pancreatitis

Gastric outlet obstruction: blockage of contents from stomach to duodenum

Question 12

What is dyspepsia?

Answer 12

Indigestion

Question 13

What are the clinical features of dyspepsia?

Answer 13

Epigastric pain
Nausea
Heartburn
Post-prandial fullness
Early satiation
Belching
Bloating
Acid taste due to reflux

Question 14

Causes of dyspepsia?

Answer 14

Peptic ulcers
GORD
Gastro-oesophageal cancer

Question 15

Management of dyspepsia.

Answer 15

Lifestyle changes

• weight loss
• drink less alcohol
• avoid hot drinks + spicy food

PPIs

Prokinetic agents: enhances gastro-intestinal motility

H. pylori eradication as necessary

Question 16

How does mucosal ischaemia cause ulcers?

Answer 16

Not enough blood supply to the epithelium
Cells die
This leaves weaknesses in the epithelium
Ulcers develop

Question 17

How can you arbitrarily distinguish between benign and malignant ulcers?

Answer 17

Benign ulcers are usually punched out with clear margins and with no build up around edges

Question 18

How can you eradicate and H pylori infection?

Answer 18

Clarithromycin

And either amoxicillin or metronidazole