Week 3: Peptic ulcer disease

Question 1

peptic ulcer disease definition

Answer 1

• gastric and duodenal ulcers
• break in lining due to loss of cells from mucosa extending through lamina propria to at least the depth of muscular mucosa
• gastric ulcers have malignant potential

Question 2

Clinical presentation of PUD

Answer 2

-abdominal pain: classically intermittent epigastric pain 2-3 hours after meals, relieved with food or antacids
COMPLICATIONS
-bleeding ulcer: hematemesis, melena, hematochezia. Rx with endoscopic therapy, IV PPI for high risk and oral PPI for low risks (clean base of ulcer)
-gastric outlet obstruction: postprandial nausea, vomiting. Succussion splash, large gastric volume. Rx: NPO, hydration, IV PPI or H2 blocker. dilation/surgery.
-penetration (pancreatitis)

Question 3

Pathogenesis of PUD

Answer 3

• imbalance of aggressive and defensive factors
• defensive factors: unstirred layer of mucus and bicarb, surface epithelial cells, cell renewal, alkaline “tide”, microcirculation-PGs, NO, protect cells from injury, sensory nerves, Prostaglandins working synergistically with NO

Question 4

Causes of ulcers

Answer 4

1. H pylori: gram neg bacteria.
   - contracted early on.
   - produces locally toxic substances (urease -forming ammonia)
   - induction of mucosal immune response: IL8, inflammatory cells
   - increased gastrin, HCl secretion by decreasing astral somatostatin
2. NSAIDs
3. acid hypersecretory state (zollinger-ellison syndrome)

Question 5

Diagnostic testing for H. pylori

Answer 5

1. Invasive: endoscopy with biopsy
   - rapid urease assay test: breakdown of urea into ammonia and bicarb results in pH increase
   - histology
   - culture: usually not done
2. Non invasive
   - serology testing: IgG antibodies to HP. Less accurate than other tests.
   - urea breath test: patients ingest urea, breath tested for labeled CO2
   - stool antigen testing: enzyme immnoassay. high sensitivity and specificity for baseline screening.

Question 6

Treatment for H. pylori

Answer 6

1. triple therapy PPI-A-C
   -amoxicillin, clarithromycin, PPI
2. Quadruple therapy PPI-BMT
   -metronidazole
   -bismuth subsalicylate
   -tetracycline
   -PPI
   Follow up with urea breath test or stool antigen test

Question 7

NSAIDs gastropathy

Answer 7

• regular NSAIDs users: dyspepsia, erosions, ulcers
• 4x increase in GI complications
• increased risk with hx of peptic ulcer, prior GI complication, use of steroids, anticoagulation drugs,
• pathophys: inhibition of mucosal prostaglandin synthesis->increased acid secretion, decreased bicarb,
• most important mechanisms of injury: decreased mucosal blood flow and neutrophil adherence to endothelium

Question 8

Treatment of PUD

Answer 8

1. Relieve symptoms and heal ulcers: Acid suppression via PPI
   - or H2 antagonist
   - anticholinergics
   - antacids
2. prevent ulcer recurrence: eliminate H pylori with triple or quad therapy, avoid NSAIDs, enhance mucosal defense