Peptic ulcers zero to finals

Question 1

Peptic Ulcers

What are they?

What is more common?

Answer 1

Peptic ulcers involve ulceration of the mucosa of the stomach (gastric ulcer) or the duodenum (duodenal ulcer).

Duodenal ulcers are more common.

Question 2

Causes

Answer 2

There is a protective layer in the stomach comprised of mucus and bicarbonate secreted by the stomach mucosa. This protective layer can be broken down by:

• Medications (e.g. steroids or NSAIDs [e.g. iburpofen, naproxen])
• Helicobacter pylori

Increased acid can result from:

• Stress
• Alcohol
• Caffeine
• Smoking
• Spicy foods

Question 3

Clinical Features

Answer 3

Epigastric discomfort or pain (eating typically worsens the pain of gastric ulcers and improves the pain of duodenal ulcers)

Nausea and vomiting

Dyspepsia

Bleeding causing haematemesis, “coffee ground” vomiting and melaena

Iron deficiency anaemia (due to constant bleeding)

Question 4

Diagnosis

Answer 4

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

Question 5

Management

Answer 5

High dose proton pump inhibitors

H. pylori eradication therapy: amoxicillin (metronidazole if pen allergic) + clarithromycin + omeprazole BD for 7 days

Endoscopy 6-8 weeks after PPI therapy used to monitoring the ulcer to ensure it heals and to assess for further ulcers.

Lifestyle modification

Question 6

Complications

Answer 6

Bleeding from the ulcer is a common and potentially life threatening complication.

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 a narrowing of the pylorus (the exit of the stomach) causing difficulty in emptying the stomach contents. This is known as pyloric stenosis. This presents with upper abdominal pain, distention, nausea and vomiting, particularly after eating.

Question 7

Folllow up after H pylori eradication therapy

Answer 7

Four to eight weeks after initial eradication therapy, patients can be re-tested for H. Pylori to check it has been eradicated.

This is especially important if the patient:

• has a personal or family history of gastric cancer
• has a past or current ulcer
• has mucosa-associate lymphoid tissue (MALT) lymphoma
• has continuing dyspeptic symptoms

Carbon-13 urea breath test is recommended for re-testing because other tests are not validated for the purpose.

The patient should not have taken antibiotics or bismuth products for four weeks and no PPI for two weeks.

Question 8

If a the follow up, h pylori has not been eradicated: what next?

Answer 8

Another course of triple therapy: with clarithromycin / metronidazole/ ciprofloxacin (Whatever was not used in the initial therapy) + amoxicillin + omeprazole

If 2 courses don’t work: refer to gastroenterologist