PUD

Question 1

List some DDx of melena?

Answer 1

Upper GI (proximal to ligament trietz/duodenum suspensory lig)
- Vascular
• Oesophageal varices (portal HTN, chronic alcoholic)- rarely causes melena
• Epistaxis (pseudo-haematemesis)
• Angiodysplasia (e.g. GAVE)
• AVM
• Aorto-enteric fistula (if prev aortic graft)
• Dieulafoy’s lesion (large, tortuous arteriole in stomach wall, erodes and bleeds)
- Traumatic
• Mallory-Weiss Tears (if severe vomiting/coughing)
• Neoplasia- gastric ca, oesophageal ca, duodenal ca
- Inflammatory
• Peptic ulcer- duodenal (most common), gastric (causes: H.pylori, NSAIDs, idiopathic) (55%)
• Gastro-duodenal erosion (acute ulceration, e.g. ETOH)
• Gastritis
• GORD
• CD (duodenum)
- Infective- gastroenteritis
Lower GI
- Strictures, ulcers
- Polyps
- Colon ca
AI disease- UC, CD
Coagulopathy- bleeding diathesis (e.g. vWF)

Question 2

List signs of anaemia?

Answer 2

• pallor
• palmar crease pallor
• angular stomatitis
• conjunctival anaemia

Question 3

Describe H. pylor testing?

Answer 3

H. pylori testing:
o Rapid urease test: biopsy, urea and indicator
- If urease present, urea -> ammonia -> increasing pH (colour change)
o C-13 urea breath test: urea labelled with carbon-13 radioisotope swallowed
- If urease present, will split the urea and carbon-13 -> detected in exhaled CO2
o Serum IgM
o Stook antigen test

Question 4

Describe the pathophysiology of black, tarry stools?

Answer 4

Melena (tarry, black stool) is secondary to upper GI bleeding
⇒ Digestive chemicals and intestinal bacteria cause oxidation of the iron in Hb as it passes through the ileus and colon

Question 5

Describe the arterial supply of the stomach?

Answer 5

From coeliac trunk branches (3):

1) L gastric -> lesser curvature
2) Splenic -> spleen, pancreas, L gastro-omental a
3) Common hepatic a -> R gastric a (lesser curvature), gastroduodenal a

Arterial supply by stomach region:
o Lesser curvature: R gastric artery (inferiorly), L gastric artery (superiorly)
o Greater curvature: R gastroepiploic and gastro-omental arteries (inferiorly), L gastroepiploic and gastro-omental arteries (superiorly)
o Fundus and upper portion of greater curvature: short gastric arteries

Question 6

What arteries are involved in a gastric ulcer UGI bleed?

Answer 6

Duodenal ulcer:
Through posterior duodenal wall -> gastroduodenal a and pancreaticoduodenal branches

Gastric ulcer:
o Through lesser curvature -> L gastric a branches
o Through posterior stomach wall -> splenic artery (large haemorrhage)

Question 7

Describe the posterior relations of the stomach and duodenum?

Answer 7

Posterior:
o Splenic artery and posterior gastric artery
o Lesser sac
o Tail of pancreas
o L adrenal gland
o L kidney
o Transverse mesocolon
oSpleen (posterolaterally)

Question 8

Describe the anterior relations of the stomach and duodenum?

Answer 8

Anterior:
o L lobe of liver
o Diaphragm
o Peritoneum
o Rectus abdominis 
o Anterior abdominal wall

Question 9

Describe the superior and inferior relations of the stomach and duodenum?

Answer 9

Superior:
o L hemi-diaphragm
o Lower oesophagus
o Oesophageal hiatus

Inferior:
o Greater omentum (hangs from greater curvature)

Question 10

What are the complications of gastric ulcers?

Answer 10

1. GI bleed (15%)- erosion of gastric or duodenal mucosa to damage BV
   - duodenal -> gastroduodenal a -> haematemesis, melena
   - gastric -> splenic a -> severe haemorrhage ->hypovolaemic shock
2. Perforation (20%)
   - erosion through stomach or duodenal (more common) wall -> spill contents into peritoneum -> peritonitis
3. Obstruction- recurrent ulcers -> inflammation, scarring, fibrosis -> pyloric stenosis -> pyloric outlet obstruction
4. Penetration
   - ulcers penetrates stomach or duodenal wall -> into adjacent organ -> fistula formation

Question 11

Describe the course of the splenic artery?

Answer 11

Pathway: Abdominal aorta -> coeliac trunk -> splenic artery

Relations:

• Tortuous, spiral-like path from coeliac trunk along superior border of pancreas towards the spleen
• Posterior to stomach

Question 12

How do you prevent recurrence of gastric ulcers?

Answer 12

Treat the cause: H. pylori (most common), NSAIDs, smoking

Rx. H. pylori
• First line: triple therapy: PPI + Amoxicillin + Clarithromycin
i) PPI- omeprazole 200mg PO, BD, x7 days
ii) Amoxicillin- 1g PO, BD, x7 days
iii) Clarithromycin- 500mg PO, BD, x7 days
- If hypersensitive to penicillin, sub amoxicillin with metronidazole

• Second line: quadruple therapy: PPI + Bismuth agent + Metronidazole + Tetracylcine
• Third line: Levofloxacin salvage therapy, Rifabutin salvage therapy