Treatment of peptic ulcers

Question 1

Recall the 2 main presenting features of a peptic ulcer

Answer 1

1. Epigastric pain

2. Burning sensation after meals

Question 2

Recall the 3 investigations done for peptic ulcers, and which of these is the gold standard

Answer 2

Gold standard = endoscopy
Carbon urea breath test
Stool-antigen test for H pylori

Question 3

Describe the basis of a carbon urea breath test and the implication of a positive result

Answer 3

Give patient loads of unique carbon isotope-urea and if you get increased levels of specific-isotope CO2 being exhaled = positive for H pylori

Question 4

How can the history differentiate between a peptic and peptic and duodenal ulcer?

Answer 4

Pain at meal times = peptic (gastric acid) whereas if meal relieves pain = duodenal (pyloric sphincter closure)

Question 5

`What is the most common cause of peptic ulcer?

Answer 5

Bacterial infection with H Pylori

Question 6

In around what % of the population is H pylori commensal?

Answer 6

50%

Question 7

How does H pylori infection cause development of a peptic ulcer? (2 steps”

Answer 7

1. It produces urease which can break down the protective mucous layer
2. It releases exotoxins at the epithelium, leading to IL8 release and local inflammation

Question 8

How do NSAIDS cause development of peptic ulcers?

Answer 8

Directly cytotoxic, reducing mucous production and causing IL8 release at epithelium

Question 9

What is the first line treatment for H pylori + peptic ulcers?

Answer 9

Amoxycillin combined with Clarithromycin/ metronidazole, and a PPI for 7-14 days

Question 10

Describe the treatment of a recurrent peptic ulcer?

Answer 10

1. Amoxycillin, clarithromycin and metronidazole given together with quinolone
2. Bismuth
3. Omeprazole (PPI) for 4-12 weeks

Question 11

How do PPIs reduce gastric acid secretion?

Answer 11

Inhibit proton pump on apical side of parietal cells

Question 12

If NSAID cannot be removed, how is an NSAID-induced peptic ulcer treated?

Answer 12

PPI or H2 antagonist

Question 13

Why would an H2 receptor antagonist be useful in peptic ulcer treatment?

Answer 13

H2 receptors on parietal cells stimulate proton pump to increase acid secretion

Question 14

Recall the function of prostaglandins in the stomach

Answer 14

PROTECTIVE

1. Increase blood supply to stimulate mucous production
2. Increase HCO3- production
3. Decrease acid production

Question 15

Recall the risk factors for peptic ulcers

Answer 15

1. Stress
2. genetic
3. Lifestyle (diet/ alcohol/ smoking)

Question 16

Recall 3 molecules that inhibit gastric acid production

Answer 16

1. Secretin
2. GIP
3. Somatostatin

Question 17

Recall the site of production on somatostatin and its role in stomach regulation

Answer 17

Produced in D cells of stomach

Role: When stimulated by PNS, inhibits histamine release –> less acid produced

Question 18

Recall the site of production on gastrin and its role in stomach regulation

Answer 18

Produced in G cells of stomach

1. Stimulates H cells to produce histamine
2. Directly triggers acid production by parietal cells

Question 19

Give an example of a histamine antagonist used in peptic ulcer therapy

Answer 19

Ranitidine