PUD - Peptic Ulcer Disease Flashcards
Define PUD
Ulceration of the distal esophagus, stomach and/or duodenum secondary to excessive acid production or damaged barrier mechanisms
What are the most common sites for ulceration in PUD?
Duodenum > Gastric > oesophagus
1st part of duodenum > Gastric antrum > lesser curve of stomach
Compare the peak age of gastric and duodenal ulcers
Duodenal ulcers occur in younger patients than gastric
Duodenal = 25-50
Gastric >50
Compare the incidence of PUD based on gender
Male:Female 3:1. you only need to say male>female
State the 2 main RFs/causes of PUD
State 5 other RFs/causes of PUD
Main: H.Pylori and NSAID use
Other: Gastrinoma/Zollinger-Ellison Syndrome, Smoking, steroids, long-term use of PPIs, blood group O, Burns, Head injuries
H. Pylori is responsible for 70-80% of gastric ulcers and 90% of duodenal ulcers. How does H.Pylori lead to PUD?
It causes chronic Antral gastritis (inflammation in the antrum) => causing increased acid secretion and decreased mucosal resistance (definition of PUD)
NSAID use increases the risk of PUD by 40x for gastric ulcers and 8x for duodenal ulcers. How does chronic NSAID use lead to PUD?
NSAIDs such as Ibuprofen inhibit the COX 1 and 2 enzymes. COX 2 is responsible for inflammation and pain and hence this is the target. Inhibiting COX 1, however, leads to suppression of Prostaglandin responsible for acid homeostasis and hence this will lead to increased acid secretion (reduced inhibition of secretion)
What is Zollinger Ellison Syndrome? What is it caused by?
How is it screened for?
It is a syndrome of increased gastrin secretion (hypergastrinemia). This is typically caused by a neuroendocrine tumor in the duodenum and pancreas, a Gastrinoma, which hypersecretes gastrin.
Detected via fasting serum gastrin
Gastrinomas are one of the rarer causes of PUD. Most cases of Gastrinomas are sporadic but what gene is associated with it?
Where are Gastrinomas typically found? Where are their ulcers found
What syndrome can it cause?
How are they typically diagnosed?
MEN1 gene: MULTIPLE Endocrine Neoplasia Syndrome (3Ps)
Typically in the duodenum or pancreas. MULTIPLE ulcers in the stomach, duodenum and jejunum
The neuroendocrine tumour causes hypersecretion of gastrin which by definition is Zollinger-Ellison syndrome leading to increased acid secretion
Diagnosed typically via Gastric Antral Biopsy via OGD with MULTIPLE ulcers in the stomach duodenum and jejenum (must say this once)
A patient with PUD typically complains of pain in which region?
Epigastric
State the clinical features of UNCOMPLICATED PUD, while comparing duodenal and gastric ulcers.
Burning intermittent epigastric pain
Gastric: Non-cyclical pain, exacerbated by food, weight loss, nausea, vomiting , Fe anemia
Duodenal: Cyclical pain worse at night and early morning, impacting sleep, relieved by food,
less common weight loss, nausea, vomiting, Fe anemia
Heartburn, reflux, chest pain
What are the complications of PUD, stating the symptoms that arise from them
1) Bleeding/hemorrhage
=> Hematemesis and malaena
=> Shock: Tachycardia, tachypnea, hypotension and altered GCS
=> Anemia: Pallor, fatigue, lethargy, chest pain, SOB/dyspnea, dizziness, syncope
2) Perforation + Sepsis: Tachycardia, tachypnea, hypotension, diaphoresis, clammy sweaty cool peripheries, reduced urine output, altered GCS
3) Gastric outlet obstruction: episodic projectile vomiting unrelated to eating => often dehydrated and malnourished
What would you be looking for on an abdominal exam for a patient with suspected gastric outlet obstruction?
Succussion Splash: splash on auscultation of the stomach when moving the patient suddenly
Without comparing duodenal and gastric ulcers, state the general symptoms of COMPLICATED PUD.
uncomplicated PUD:
Burning, intermittent epigastric pain
Nausea, vomiting
mild weight loss
heartburn, reflux, chest pain
+ complications:
1) Bleeding/hemorrhage
=> Hematemesis and malaena
=> Shock: Tachycardia, tachypnea, hypotension and altered GCS
=> Anemia: Pallor, fatigue, lethargy, chest pain, SOB/dyspnea, dizziness, syncope
2) Perforation + Sepsis: Tachycardia, tachypnea, hypotension, diaphoresis, clammy sweaty cool peripheries, reduced urine output, altered GCS
3) Gastric outlet obstruction: episodic projectile vomiting unrelated to eating => often dehydrated and malnourished
QUICK: A patient presents to you with epigastric pain. What are your ddx?
PUD
GORD
Cholelithiasis/biliary colic
Acute cholecystitis
Pancreatitis
Gastric neoplasm
Pancreatic neoplasm