Peptic Ulcers - Gastric + Duodenal

Question 1

Definition

Answer 1

Break in the lining of the gastric or duodenal mucosa
Look like round clean base with punched out hole

Question 2

Epidemiology

Answer 2

Elderly
Developing countries due to H. Pylori
Blood type O

Question 3

Risk factors

Answer 3

H. Pylori
Drugs:
- NSAIDs (inhibit cyclo-oxygenase resulting in reduced prostaglandin which normally inhibits acid secretion + increase mucus production
- SSRIs,
- Corticosteroids,
- Bisphosphonates
Smoking and alcohol
Stress
Raised intercranial pressure: vagal stimulation = increases acid production (Cushing’s ulcer)
Zollinger-Ellison syndrome = gastrinoma results in numerous peptic ulcers due to elevated gastrin levels

Question 4

Aetiology Gastric

Answer 4

H. Pylori (spiral shaped gram negative urease secreting bacteria)
NSAIDS
Zollinger-Ellison Syndrome (Gastrin secreting tumour TRIAD:)
- Pancreatic tumour
- Gastric acid hypersecretion
- Widespread peptic ulcers

Question 5

Aetiology Duodenal

Answer 5

H. Pylori (MC)
NSAIDS
Zollinger Ellison Syndrome

Question 6

Pathophysiology

Answer 6

Break in mucosal lining of the stomach, duodenum or lower oesophagus more than 5mm diameter with depth to the submucosa.

Question 7

Where are gastric ulcers most commonly found

Answer 7

Lesser curvature of the gastric antrum but can be found anywhere in the stomach

Question 8

Where are duodenal ulcers most commonly found

Answer 8

2-3 times more common than peptic ulcers
1st part of duodenum = duodenal cap
2nd part = posterior medial aspect of duodenal wall
* deeply penetrating ulcers in this region can result in torrential upper GI bleed due to the gastroduodenal artery located here *

Question 9

Signs Gastric specific (better or worse on eating?)

Answer 9

EPIGASTRIC PAIN
- Worse on eating
- Better between meals + with antacids
* typically wt loss *

Question 10

Signs Duodenal Specific (better or worse on eating?)

Answer 10

EPIGASTRIC PAIN
- Worse between meals
- Better with food
* typically weight gain *

Question 11

Signs general

Answer 11

Evidence of bleeding
- Hypotension and tachycardia
- Melaena on rectal examination
Epigastric tenderness
Pallor if anaemic

Question 12

Symptoms

Answer 12

Nausea + Vomiting
Coffee-ground vomiting or melaena if bleeding
Reduced appetite and weight loss
Anaemia e.g. fatigue, angular stomatitis, glossitis, dizziness, pallor

Question 13

Diagnosis

Answer 13

FIRST LINE (No red flags: 55+, haematemesis/melaena, dysphagia):
- c-urea breath test
- stool antigen test
= 2 weeks without PP
= 4 weeks without Abx
GOLD STANDARD (if red flags): URGENT ENDOSCOPY + BIOPSY
- In duodenal ulcers = will see Brunners gland hypertrophy = more mucus production)

Question 14

Treatment

Answer 14

STOP NSAIDS
Eradicate H. Pylori = Clarithromycin, Amoxicillin, Lansoprazole
(Can also be Metronidazole if penicillin allergy)
If PUD found = rescope 6-8 weeks

Question 15

Healed

Answer 15

Low dose PPI
Persistent symptoms = low dose PPI
PPI intolerant = H2 receptor antagonist = ranitidine

Question 16

Not healed

Answer 16

Could be malignancy
Try another H. Pylori regimen
4 more weeks of PPI

Question 17

Complications

Answer 17

Bleeding
- more common in duodenal ulcers = ruptured gastroduodenal artery
- less common in gastric ulcers = ruptured left gastric artery