GI: Peptic Ulcer Disease

Question 1

What is peptic ulcer disease? Describe the possible causes for this.

Answer 1

PUD = breach in gastric or duodenal mucosa, extending through muscularis mucosa, secondary to gastric acid.
Most commonly affects posterior wall or early duodenum or lesser curve of stomach.

Causes:

1. H. pylori infection (associated with 95% duodenal ulcers and 80% gastric ulcers)
2. NSAID or corticosteroid use (breakdown of mucosal defence mechanisms due to inhibition of prostaglandin synthesis)
3. Severe physiological stress, e.g. burns, RICP
4. Zollinger-Ellison syndrome (gastrin-secreting gastrinoma)

Question 2

describe the presentation of peptic ulcer disease

Answer 2

• Severe constant epigastric pain (may radiate to back if posterior ulcer) - burning/gnawing usually 1-3 hrs post-prandial.
• Aggravated by eating if gastric, relieved by eating if duodenal.
• Nausea, bloating, distension
• +/- heartburn

Question 3

which tests would you perform in a pt with suspected PUD?

Answer 3

1. Carbon-13 urea breath test for H. pylori (or stool antigen test)
2. Endoscopy to confirm ulceration and for biopsy, IF pt >55 yo at 1st presentation, or presence of red flags

Question 4

how would you manage a pt with PUD who is H. pylori +ve? -ve?

Answer 4

1. Lifestyle modification: stop NSAIDs if possible, stop smoking
2. If H. pylori +ve: 7 days of triple therapy for eradication - PPI + clarithromycin + amoxicillin
3. If H. pylori -ve: 4-8 wks PPI

Review at end of Tx course, e.g. f/u urea breath test after eradication.

Question 5

describe 2 possible complications of PUD?

Answer 5

1. Upper GI tract haemorrhage (14%): haematemesis or melaena as a result of deep ulcers eroding into underlying blood vessels (usually L gastric artery or gastroduodenal artery)
2. Perforation (6%): peritonitis