Gastroenterology; Upper GI; Peptic Ulcer Disease

Question 1

Define peptic ulcer disease [1]

Answer 1

Peptic ulcer disease may be defined as ulceration in the stomach or duodenum

NB: many patients are managed with the clinical diagnosis of ‘dyspepsia’ as opposed to the endoscopic diagnosis of peptic ulcer disease.}

Question 2

PUD is highly correllated to which organism? [1]

Answer 2

H. pylori

Question 3

Describe the clinical features of peptic ulcer disease [3]

Answer 3

• Epigastric pain that radiates to the back
• N & V
• Dyspepsia

Question 4

Describe pathophysiology of PUD [2]

Answer 4

The mucosa lining inner lining of the stomach and duodenum secretes bicarbonate into this mucus coating to neutralise stomach acid & digestive enzymes

Disruption of the mucus barrier or increase stomach acid increase the risk of mucosal ulceration.

Question 5

Risk factors for PUD? [6]

Answer 5

Helicobacter pylori is associated with the majority of peptic ulcers:
- 95% of duodenal ulcers
- 75% of gastric ulcers

Drugs:
- NSAIDs
- SSRIs
- corticosteroids
- bisphosphonates

Zollinger-Ellison syndrome

Question 6

State for duodenal or gastric ulcers the following:

• % related to H.pylori
• Weight loss is more likely
• If malignant

Answer 6

Duodenal:
- 95/99% related to H.pylori
- Not malignant (most cases)
- Weight loss less likely

Gastric:
- Weight loss likely (pain on eating)
- 60/70% related to H.pylori
- NSAIDs significant cuase
- 5-10% malignant

Question 7

What investigations would you conduct for H. pylori ? [3]

Answer 7

Helicobacter pylori should be tested by:
- either a Urea breath test (goes red)
- stool antigen test should be used first-line
- endoscopy: rapid urease test (CLO test) can be performed to check for H. pylori. A biopsy is considered during endoscopy to exclude malignancy.

Question 8

How can you distinguish between duodenal and gastric ulcers based off symptoms? [4]

Answer 8

Eating typically worsens the pain of gastric ulcers.
The pain of duodenal ulcers tends to improve immediately after eating, followed by pain 2-3 hours later

Patients with gastric ulcers tend to lose weight due to the fear of pain on eating.
Duodenal ulcers, the weight is stable or increases

Question 9

Describe management of PUD [4]

Answer 9

PPI:
- lansoprazole
- omeprazole

Treat H.pylori using triple therapy (x2 antibiotics; x1 PPI)

Stop NSAIDs

Confirm eradicaiton using endoscopy and / or faecal antigen or urea breath test

Question 10

Why do NSAIDs increase chance of gastric related ulcers? [1]

Answer 10

Inhibition of COX-1 in the gastrointestinal tract leads to a reduction of prostaglandin secretion and its cytoprotective effects in gastric mucosa

Question 11

Describe the different pathways for duodenal and gastric ulcer pathways

Answer 11

Duodenal ulcer pathway;
antral gastritis, increased acid secretion which causes gastric metaplasia in the duodenal and leads to a duodenal ulcer

Gastric ulcer pathway:
corpus gastritis – inflammation in the body of the stomach, decreased acid secretion which causes gastric atrophy and predisposes you to dysplasia/neoplasia.

Question 12

Why do you always biopsy a gastric ulcer? [1]

Answer 12

Confirm if is due to malignancy or not

Question 13

Describe the managment for patients who have recurrent peptic ulcers [3]

Answer 13

Reducing the NSAID dose & substituting the NSAID with paracetamol

If symptoms recur after initial treatment: offer a PPI at the lowest dose possible to control symptoms:
* esomeprazole
* lansoprazole
* omeprazole

Offer H2 antagonist therapy if there is an inadequate response to a PPI:
- famotidine
- nizatidine

BMJ Best Practise

Question 14

When should barium radiography be used for investigating POD? [1]

Answer 14

Barium radiography should be reserved for patients who are unable or unwilling to undergo endoscopy, and it is not routinely recommended.

Question 15

Describe complications of significant peptic ulcerations [4]

Answer 15

Haematemesis (vomiting blood)
Coffee ground vomiting
Melaena (black, tarry stools)
Fall in haemoglobin on a full blood count

Question 16

Why could an acute ulcer perforation cause abdominal ‘board like rigidity?’

Answer 16

Causes generalised peritonitis: presents with characteristic “boardlike” rigidity of the abdominal wall

Question 17

Where is the most common place for duodenal ulceration?

Answer 17

Duodenal ulcers occur most frequently in the first portion of the duodenum (over 95%), with approximately 90% located within 3 cm of the pylorus and are usually less than or equal to 1 cm in diameter

Question 18

In a patient with upper abdominal symptoms, what would indicate a perforated peptic ulcer on AXR? [1]

Answer 18

Free air on an erect chest X-ray

Classic example of gross pneumoperitoneum from a perforated gastric ulcer presenting as subdiaphragmatic free gas on chest x-ray. The patient report recent NSAID and heavy alcohol use.

Question 19

What is the classical presentation of perforated stomach ulcer (classic triad and others?) [6]

Answer 19

The classical triad:
- abdominal pain
- tachycardia
- abdominal rigidity.

Additional:
- Peritonitis
- Abdominal distention & tenderness
- Fever
- Nausea and vomiting
- Dyspepsia
- Constipation
- Anaemia

In practice, most patients present with symptoms of an acute abdomen.

Question 20

Investigations for perforated peptic ulcer? [5]

Answer 20

Bloods:
- Leukocytes present
- Anaemia

U & E:
- Significant bleeding may alter electrolytes
- Urea may be raised: digested blood is protein source

Liver function: useful to rule out biliary pathology

XR:
- upright XR if acute upper abdominal pain
- See free air presence

CT scan: if not seen on XR, but clinical presentation suggests

Question 21

Describe the treatment pathway for the initial resuscitation of perforated peptic ulcer disease [4]

Answer 21

IV fluids

Nasogastric tube insertion:
- reduces amount of gastric fluids in GIT AND allows nill by mouth

IV PPI
- loading and maintence doses
- enhance sealing of perforation

Antibiotics:
- stop sepsis due to leaking of fluids into peritoneum

Question 22

After initial resuscitation, describe the operative management for PPUs [3]

Answer 22

Operative:
- Closure of perforation < 2 cm ulcer
- Resection of lesion > 2cm ulcer
- Use piece of omentum to cover}

Question 23

Describe the post-op management of PPUs [2]

Answer 23

Upper endoscopy:
- ID cause of perforation & healing of ulcer
- Biopsy for H. pylori

H.pylori eradication:
- triiple therapy for 10-14 days

Question 24

Describe what is meant by Zollinger-Ellison syndrome [1]

It is made from a triad of which three causes? [3]

Answer 24

Zollinger-Ellison syndrome (ZES) is a condition caused by a gastrin-secreting tumour that causes hypersecretion of gastric acid leading to ulcer disease.

Triad:
1) gastric acid hypersecretion, sustained by:
2) fasting serum hypergastrinemia causing:
3) peptic ulcer disease and diarrhea