PUD

Question 0

Which is more common duodenal or gastric?

Answer 0

Duodenal is 2-3X more common than gastric

DU - 20-50
GU - >40

Question 1

What is the most common cause of bleeding PUD?

Answer 1

NSAID use

Question 2

RFs?

Answer 2

NSAIDs
Smoking
Alcohol
H. Pylori

Question 3

What is an ulcer?

Answer 3

Mucosal defect >/= 5mm

Penetrates into muscularis mucosar

Question 4

What is a stress ulcer?

Answer 4

Bleeding ulcer in the context of critical illness.

Question 5

What are common causes of PUD?

Answer 5

H. Pylori infection and NSAID = 90%
Stress ulcer
Gastric or pancreatic cancer
Mes enteric vascular occlusion (Dx with angiography) 
Crohn's disease

Question 6

What is Zollinger-Ellison syndrome?

Answer 6

Gastric secreting tumour

Rare cause of PUD

Question 7

NSAID effect in PUD?

Answer 7

NSAIDs inhibit COX-1 -> decrease Pg synthesis -> decreases GIT mucosal integrity and platelet aggregation

Question 8

H. Pylori effect?

Answer 8

Increased inflammation

Question 9

S and S?

Answer 9

Epigastric ABDO pain associated with meals, relieved with antacids
N + V
Malaena/haematemesis (obstruction)

Question 10

DU OR GU worse after meal?

Answer 10

Duodenal usually occurs after meals

Question 11

How would a “silent” ulcer present?

Answer 11

Haemorrhage or perforation, often after NSAID ulcers.

Question 12

Complications of PUD? What signs and symptoms of complications?

Answer 12

Haemorrhage -> IDA - SOB, fatigue, palpitations, ortho static dizziness
PERFORATION -> peritonitis: sharp severe , widespread abdominal pain
Penetration -> Pancreatitis: epigrastric pain radiating to pain, relieved by leaning forward
Gastric outlet obstruction (ulcer induced fibrosis/scarring): satiety, inability to ingest food, sucussion splash

Question 13

Ix?

Answer 13

Lab
CBE EUC LFTs
H. Pylori - urea breath test

Radiological
Endoscopy with biopsy of gastric mucosa (IDEAL)
barium contrast

Question 14

Diagnosis?

Answer 14

Endoscopy shows mucosal break > 5mm
- look for crohns
- ischemia 
- Zollinger-Ellison syndrome 
If < 55, H. Pylori diagnosis sufficient, don't do endoscopy

Question 15

Management?

Answer 15

PPI - healing and prevent small ulcers

• uncomplicated DU: no PPI after eradication
• GU: PPI for 4-8 weeks after
• if complications, PPI cont until endoscopic evidence of healing

H.pylori eradication
- triple therapy: PPI, clarithomycin, amoxicillin (7 days)

Once PUD healed clinically, perform endoscopy to rule out underlying carcinoma

Surgery for complicated PUD

Question 16

What if can’t use amoxicillin?

Answer 16

PPI
CLARITHROMYCIN
METRONIDAZOLE

FOR 7 DAYS

Question 17

What if can’t use CLARITHROMYCIN?

Answer 17

PPI
AMOXYCILKIN
METRONIDAZOLE

14 days

Question 18

What are negative prognostic indicators for UGIB?

Answer 18

OLD 
BLEEDING 
ONSET IN HOSPITAL
COAGULOPATHY
COMORBIDITIES

Question 19

Pre endoscopic management of bleeding ulcer?

Answer 19

NBM
NGT
IV PPI
IV PROKINETIC AGENT (erythromycin/metoclopramide) 
If clinically Ill -> tranexemic acid

Question 20

Failing endoscopy?

Answer 20

Ballon tamponade
TIPS
Surgery and interventional radiology

Question 21

Endoscopic techniques to stop bleeding ulcers?

Answer 21

Band ligation
Sclerotherapy
Adrenaline injection

Question 22

Differential for severe upper GI bleed?

Answer 22

PUD
GASTRIC/OESOPHAGEAL VARICES
EROSIVE OESOPHAGITIS
UPPER GI TUMOUR
UPPER GI ANGIOMA
MW TEAR

Question 23

Differentials for lower GI bleed?

Answer 23

Bleeding diverticular disease 
Internal haemorrhoids
Bowel ischemia -> ischemic colitis
Rectal ulcers 
Colonic angiodysplasia 
IBD
CRC or Polyp

Question 24

Occult GI bleed?

Answer 24

CRC
ANGUECTASIAS
ULCERS
TUMOURS