10/5- Peptic Ulcer Disease and Helicobacter Pylori

Question 1

What is dyspepsia?

Answer 1

Epigastric pain or discomfort

• Recurrent
• Relief obtained by eating or taking antacids

Question 2

What is the DDx for dyspepsia?

Answer 2

• Peptic disease
• Gastroesophageal reflux disease (GERD)
• Unknown (Non-ulcer dyspepsia)

Question 3

What is peptic ulcer disease?

• Symptoms
• Prognosis

Answer 3

• Abdominal pain
• Reduced quality of life
• Risk of complications (~25%)
• Costs (drugs, doctor visits, tests, lost time from work, etc)
• Increased mortality compared to those without ulcer disease

Question 4

What characterizes:

• Erosion
• Ulcer
• Penetrating ulcer

Answer 4

• Erosion: into mucosa
• Ulcer: into muscularis mucosa

Question 5

What is seen here?

Answer 5

Chronic gastric ulcer

Question 6

Describe ulcer pain

• Location
• Timing

Answer 6

• Epigastric
• Relates to acid cycle
• Episodic, recurrent

Question 7

Describe the pain and acid cycle

Answer 7

• Low acid in the morning
• Acid rises after meal, and brings pain
• About 1 hr after meals, pt will feel pain

Question 8

What is the most common cause of upper GI bleeding?

Answer 8

Peptic ulcer

Question 9

What are the main locations of peptic ulcers?

Answer 9

• Pyloric valve (near duodenum)
• Stomach (typically along minor curvature)

Question 10

What is seen here?

Answer 10

Peptic ulcer near pyloric valve?

Question 11

What is seen here?

Answer 11

Peptic ulcer on minor curvature of stomach?

Question 12

What is seen here?

Answer 12

From left to right:

• Active gastric ulcer
• Healing
• Healed

Question 13

What is the treatment for ulcers?

Answer 13

Heal the ulcer, relive pain

• Antisecretory therapy (proton pump inhibitor or H2-receptor antagonist)

Eliminate the cause

• Cure H. pylori infection
• Stop NSAIDs (e.g., ibuprofen)
• Control tumor-produced excess acid secretion (Zollinger-Ellison Syndrome)

Question 14

What are common causes of ulcers?

Answer 14

• H. pylori infection
• Drug use (esp NSAIDs)
• Pathologic hypersecretory states (Zollinger-Ellison syndrome)
• Rare causes (Herpes simplex, tumors, Crohn’s disease…)

Question 15

What is H. pylori infection?

• When acquired
• Prognosis

Answer 15

• Transmissible infectious disease
• Acquired in childhood
• Disease manifestations usually in adults with variable latent periods
• High morbidity, Modest mortality
• Curable

Question 16

What is this?

Describe the causative agent.

Answer 16

H. Pylori infection

• Gm
• spiral bacteria
• Niche: human stomach

Causes inflammation:

• Atrophic gastritis
• Peptic ulcer
• Gastric cancer

Question 17

Outcomes of H. pylori infection?

Answer 17

Atrophic gastritis

• > Gastric cancer
• > Gastric ulcer

Acute gastritis

Acute on chronic gastritis

• > Antral Predominant gastritis
• > duodenal ulcer
• > Lymphoma

Question 18

What are causative associations of H. pylori?

Answer 18

Progressive gastro-duodenal damage

• Disordered regulation of acid secretion

Diseases: gastric adenocarcinoma, peptic ulcer (gastric and duodenal), gastric lymphoma, atrophic gastritis, gastric atrophy, vitamin B12 malabsorption (pernicious anemia), iron deficiency anemia, idiopathic thrombocytopenia (ITP), dyspepsia, etc.

Question 19

Risk factors for Hp infection

Answer 19

• Low socio-economic status
• Birth in a developing country
• Crowded living conditions
• Sharing a bed as a child
• Absence of hot water tap in home
• Poor sanitary conditions

Question 20

How is H pylori transmitted?

Answer 20

“Situational Opportunistic transmission”; any method of gaining access to the stomach will do

• Gastro-oral (e.g. vomit)
• Fecal-oral
• Contaminated water or food

Question 21

Who should be tested for Hp?

Answer 21

• Dyspepsia
• Ulcer disease
• Present/past history
• 1st degree relatives
• Gastric cancer
• Family history of gastric cancer
• After endoscopic resection of gastric cancer
• If you plan to start therapy with: chronic NSAIDs or chronic PPI therapy (for GERD)
• Evaluate Hp eradication
• Pt desires to be tested

Question 22

What are tests for finding/treating H. pylori?

Answer 22

• Serologic (ELISA): lab based or office urine (IgG antibody tests)
• Endoscopic
• Breath tests: measure change in concentration of urea (urease converts urea -> CO2 + NH3)
• Stool antigen tests

Question 23

How good is serology for the diagnosis of H pylori?

Answer 23

• Specificity and Sensitivity good but not excellent
• Antibodies can remain for years after elimination of the infection
• Can not be used to confirm eradication
• Not generally recommended unless high pretest probability (eg, DU)

Question 24

What diagnostic methadologies are preferred for diagnosing Hp?

Answer 24

Non invasive:

• Breath tests
• Stool antigen tests

Question 25

What is seen here?

Answer 25

See hyperplasia of folia (?) - Chemical cause (think NSAIDs)

Question 26

What is seen here?

Answer 26

H. pylori infection

Question 27

What is seen here?

Answer 27

H. pylori infection

Question 28

When should endoscopy be done for Dx of Hp?

Answer 28

- **Geographic** (Korean, Japanese) - **Alarm features present**: weight loss/mass, bleeding, advanced age, long history, significant anorexia, UGI bleeding/anemia, significant vomiting, x-ray suggests 'cancer' _NOT:_ - Classic Hx GERD - Lack of alarm features

Question 29

So if pt presents with dyspepsia, what are treatment options for their answer to "are serious signs/symptoms present" or "does pt have long hx GERD"?

Answer 29

_Yes symptoms/GERD:_ - Endoscope to rule out gastric CA or Barrett's _No symptoms/GERD:_ - Non-invasive Hp testing * If test +, give multidrug Hp and confirm cure after 4 wks * If test -, give anti-secretory drug to treat symptoms

Question 30

What are the rules of thumb for Hp therapy?

Answer 30

- 2+ antibiotics; any PPI + any 2 (best with all 4): * Clarithromycin * Amoxicillin * Metronidazole - Acid suppression - Duration: 14 days - Confirm cure (UBT or stool antigen test)

Question 31

3 areas of choices for Hp eradication?

Answer 31

- Treat with antibiotics - Vaccine: therapeutic or preventative - Improve the environment (good housing, sanitation, food, clean water, no crowding...)

Question 32

What are characteristics of complicated PUD?

Answer 32

- Bleeding - Perforation - Obstruction - Penetration

Question 33

\_\_% of people with peptic ulcers develop a potentially life-threatening complication What is the most common complication?

Answer 33

25% of people with peptic ulcers develop a potentially life-threatening complication - Bleeding is most common (and more frequent with NSAID users)

Question 34

What are signs/symptoms of free perforation?

Answer 34

- Acute onset of severe pain - Board like rigidity of abdomen - Absent bowel sounds - Free air in abdomen Call surgeon!

Question 35

What is seen here?

Answer 35

Contained perforation/perforation

Question 36

What surgery can be done for PUD?

Answer 36

Attacked acid secretion physiologically - Cephalic phase -\> cut vagus - Gastric phase -\> remove antrum (gastrin) - Remove acid cells -\> gastrectomy

Question 37

What is a Billroth I procedure?

Answer 37

Removal of stomach antrum and sewn directly onto duodenum

Question 38

What is a Billroth II?

Answer 38

Question 39

What is Zollinger Ellison Syndrome?

Answer 39

Gastrin-producing tumor - Non-beta cell tumor of the pancreas that produces gastrin (malignant \>benign). - Gastrin secretion is not responsive to the normal down-regulatory events and thus causes sustained high levels of acid secretion - Gastric acid hypersecretion - Ulcers in unusual locations - Diarrhea - Parathyroid adenomas

Question 40

What are clues to Zollinger-Ellison syndrome?

Answer 40

- Non-H. pylori, non-NSAID duodenal ulcer disease - Ulcers beyond the duodenal bulb (post-bulbar ulcers) - High rates of secretion of concentrated (\>100 mmol/L) acid - High serum gastrin levels

Question 41

What is therapy for Zollinger-Ellison syndrome?

Answer 41

- Search for the tumor (often in duodenal wall). Remove if possible (benign) - Control acid secretion with sufficient doses of proton pump inhibitor medications orally

Question 42

What are the main conditions associated with elevated gastring composition? How are they distinct?

Answer 42

**Atrophic gastritis or PPI therapy** - No acid - High gastrin (normal regulation) **ZE syndrome** - High acid - High gastrin (abnormal regulation; b/c of ectopic production of gastrin)

Question 43

Describe the circuit of acid secretion/inhibition in the stomach?

Answer 43

_Cells:_ - G cell- secrete gastrin - D cell- secrete somatostatin (inhibits gastrin) - Parietal cells- secrete acid _Process:_ - Food and high pH stimulate antral gastrin release which travels via the blood to the produce acid by the parietal cells - High acid then interacts with the antral D cells which make somatostatin and turn down gastrin and thus acid secretion

Question 44

Summary: Peptic Ulcer Disease in the 21st century - The focus is on prevention, cure and treatment based on etiology. - The most common causes are infection with H. pylori and use of NSAIDs - NSAID use has rapidly become the most common cause of ulcer disease and ulcer complications

Answer 44

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