Peptic Ulcers

Question 1

What is a peptic ulcer?

Answer 1

• ulceration of the mucosa of the stomach (gastric ulcer) or duodenum (duodenal ulcer)
• duodenal ulcers are more common

Question 2

What is the pathophysiology involved in gastric ulceration?

Answer 2

the stomach mucosa is prone to ulceration from:

• breakdown of the protective layer of the stomach / duodenum
• an increase in stomach acid

Question 3

What is the protective layer of the stomach / duodenum?

How can it be broken down?

Answer 3

• the stomach mucosa secretes bicarbonate + mucus
• it can be broken down by Helicobacter pylori

OR

• medications such as NSAIDs and steroids

Question 4

What factors can increase stomach acid production?

Answer 4

• stress
• caffeine
• alcohol
• smoking
• spicy foods

Question 5

What is the typical presentation of a gastric ulcer?

Answer 5

• epigastric pain
• dyspepsia
• N&V
• if the ulcer bleeds, this results in haematemesis, coffee-ground vomit + melaena
• iron deficiency anaemia occurs due to constant bleeding

Question 6

How does eating affect the pain of gastric and duodenal ulcers?

Answer 6

• eating WORSENS the pain of gastric ulcers

AND

• IMPROVES the pain of duodenal ulcers

this can be remembered by:
* food entering the stomach irritates the gastric ulcer

• food also mops up stomach acid, preventing this from entering the duodenum and affecting the duodenal ulcer

Question 7

How are peptic ulcers diagnosed?

Answer 7

endoscopy

Question 8

What additional investigations may be considered during endoscopy for diagnosis of the ulcer?

Answer 8

rapid urease (CLO) test:

• checks for the presence of H. pylori

biopsy:

• to exclude malignancy
• gastric cancers can appear very similar to ulcers during endoscopy

Question 9

What is involved in the management of peptic ulcers?

Answer 9

• high dose PPI to reduce the amount of stomach acid and allow the ulcer to heal
• endoscopy is performed to monitor the healing of the ulcer and to assess for further ulcers

Question 10

What are the 3 major complications associated with peptic ulcers?

Answer 10

• bleeding from the ulcer
• perforation
• scarring / strictures

Question 11

How does bleeding from a peptic ulcer typically present?

Answer 11

• chronic low-level bleeding presents as an iron-deficiency anaemia
• acute haemorrhage can be a life-threatening emergency

Question 12

What does perforation of a peptic ulcer result in?

Answer 12

• perforation involves a hole being made in the stomach / duodenum
• the contents enter the peritoneum, causing peritonitis and an acute abdomen
• this requires urgent surgical repair (usually laparoscopic)

Question 13

Why does scarring / strictures occur and what can this result in?

Answer 13

• this occurs as a result of the ulcer healing
• this can result in narrowing of the pylorus (pyloric stenosis)
• this results in difficulty emptying the stomach contents
• presents with upper abdo pain, N&V + distension
• symptoms are worse after eating