Peptic ulcer disease

Question 1

What is peptic ulcer disease?

Answer 1

• A break in the mucosal lining of the stomach or duodenum more than 5mm in diameter, with depth to the submucosa.
• Ulcers smaller than this or without obvious depth are called erosions

Question 2

Causes of peptic ulcer disease

Answer 2

Two major aetiologic factors:
-Infection by gram-negative H.pylori (survives in acidic conditions)
-Use of aspirin and NSAIDs
Rarer causes include:
-Gastric ischaemia (stress ulcers)
-Hypersecretory syndromes which increase the production of stomach acid. These are rare but you may have heard of the Zollinger-Ellison syndrome.
-Certain medications (potassium chloride, bisphosphonates)
-Crohn’s disease

Question 3

Pathophysiology of peptic ulcer disease

Answer 3

Peptic ulcer result from an imbalance between factors promoting mucosal damage (gastric acid, pepsin, H.pylori and NSAIDs) and those mechanisms promoting gastroduodenal defence (prostaglandins, mucus, bicarbonate, mucosal blood flow).

Question 4

Role of H.pylori in peptic ulcer disease

Answer 4

Gastric ulcers (70%) 
Duodenal ulcers (80-95%)
-H.pylori burrows through the protective mucosa which lines the stomach, with a preference for the antrum.
-There's a destructive impact on 'D' cells within the stomach which dampen down acid production in the stomach, therefore an overall impact of increasing acid production and lowering pH of the stomach juices

Question 5

How do you test for infection with H.pylori?

Answer 5

Urea breath test
Stool antigen test
A blood test to look for antibodies

Question 6

Role of NSAIDs in peptic ulcer disease

Answer 6

NSAIDs inhibit COX-1 (decreased blood flow) and COX-2 (neutrophil adherence) and also causes topical irritation (epithelial damage).
Decreased blood flow, neutrophil adherence and epithelial damage leads to mucosal injury

Question 7

What are the types of peptic ulcer disease?

Answer 7

Gastric ulcers.

Duodenal ulcers.

Question 8

Signs and symptoms of peptic ulcer disease

Answer 8

• Abdominal pain
• ‘pointing sign’ - the patient can show site of pain with one finger
• Epigastric tenderness
• Nausea or vomiting
• Early satiety
• Diarrhoea

Question 9

Risk factors of peptic ulcer disease

Answer 9

H.pylori infection 
NSAIDs 
Smoking 
Increasing age 
Personal Hx of peptic ulcer disease 
Family Hx of peptic ulcer disease 
Patient in intensive care 
Physical stress e.g major trauma/surgery

Question 10

Investigations of peptic ulcer disease

Answer 10

H.pylori- urea breath test or stool antigen test
Upper GI endoscopy
FBC

Question 11

Differentials of peptic ulcer disease

Answer 11

Oesophageal cancer 
Stomach cancer 
GORD 
Gastroparesis 
Biliary colic 
Acute pancreatitis 
Non-ulcer dyspepsia 
Coeliac disease 
IBS 
Pleuritic pain 
Pericarditis

Question 12

Management of peptic ulcer disease

Answer 12

Active bleeding ulcer:
-Endoscopy w/without blood transfusion
-PPI (omeprazole 80mg IV bolus)
-Surgery or embolisation via IV radiology
No active bleeding: H.pylori negative-
-Treat underlying cause plus PPI
- H2 antagonist if PPI is CI
No active bleeding: H.pylori positive :
-Triple therapy (Clarithromycin 500mg BD),
Amoxicillin ( 1000mg BD), PPI (omeprazole 20-40mg OD)
-If there’s an allergy to penicillin, metronidazole is given rather than the amoxicillin

Question 13

Complications of peptic ulcer disease

Answer 13

-Penetration- into an adjacent organ like the pancreas
-Upper GI bleeding- signs of bleeding include haematemesis, melaena and haemorrhagic shock (if bleed severe)- bleeding can cause an iron deficiency anaemia
-Perforation:
Fluids and air escape into the peritoneal cavity
Acute abdomen and peritonitis
Emergency surgery needed
-Gastric outlet obstruction:
Epigastric abdominal pain and postprandial vomiting due to obstruction
Malignancy is now the predominant cause rather than peptic ulcers
Most common is pancreatic cancer extending into the duodenum and gastric outlet followed by primary gastric cancer

Question 14

Important information about gastric cancer

Answer 14

Gastric cancers are relatively uncommon
They usually present with symptoms similar to peptic ulcer disease or gastric outlet obstruction
They are most often picked up on endoscopic examination of gastro-intestinal tract and biopsies of ulcers or other abnormal-looking tissues.
Risk factors for developing gastric cancers are chronic gastritis and there is an association with H. Pylori infection.

Question 15

Which medications are linked with the formation of peptic ulcers or GI bleeds?

Answer 15

SSRIs (Selective Serotonin Reuptake Inhibitors).
Corticosteroids.
Anticoagulants.
Non-steroidal anti-inflammatory drugs (NSAIDs).
Antiplatelets.
Potassium Channel Activators – Nicorandil

Question 16

Nicorandil and peptic ulcer disease

Answer 16

Nicorandil is associated with a risk of gastrointestinal ulceration, including perianal ulceration.
Ulcers that result from nicorandil are refractory to treatment, including surgery; they respond only to the withdrawal of nicorandil.

Question 17

Should PPI be given to prevent peptic ulcers in someone taking long-term aspirin or clopidogrel?

Answer 17

Yes- only patients with a high risk
Patients at high risk are:
Patients taking high dose aspirin
Older patients
Previous history of peptic ulcer or GI bleed
With serious co-morbid conditions (Cardiovascular disease, hepatic or renal impairment, diabetes or hypertension)
With H. Pylori infection
Taking concomitant medications which also increase the risk of ulcers or GI bleed.