Peptic ulcer disease

Question 1

What is PUD?

Answer 1

• Break in lining of GI tract
• Extending through muscular layer - muscularis mucosae
• Most common in lesser curvature of proximal stomach or 1st part duodenum

Question 2

Underlying causes of PUD

Answer 2

• GI mucosa protected by surface mucous secretion and bicarbonate iron release
• Imbalance of acid and protection = ulceration
• Most commonly caused by NSAIDs or H-pylori

Question 3

How does h-pylori cause PUD?

Answer 3

• Can survive in gastric and duodenal mucosa by producing alkaline micro-environment (via urease so urea into CO2 and ammonia)
• This induces an inflammatory response in mucosa –> ulceration

Question 4

How do NSAIDs cause PUD?

Answer 4

• Inhibit prostaglandin synthesis
• = reduced secretion of glycoprotein, mucus and phospholipids by gastric epithelial cells

Question 5

Other RF for PUD

Answer 5

• Corticosteroid use (when with NSAIDs)
• Gastric bypass surgery
• Physiological stress (eg severe burns - Curlings ulcer)
• Head trauma (Cushings ulcer)
• Zollinger Ellison syndrome

Question 6

How does h-pylori induce inflammation?

Answer 6

• Produces micro alkaline environment
• Cytokine and interleukin inflammatory response
• Increasing gastric acid secretion by inducing histamine release which acts on parietal cell
• Damaging host mucous secretion by degrading surface proteins and down regulating bicarbonate production

Question 7

Symptoms of PUD

Answer 7

• Epigastric pain associated with eating
• Gastric ulcer classically exacerbated immediate after food
• Duodenal ulcer worse 2-4hrs after eating (or even alleviated via eating)
• Others - nausea, bloating, early satiety

Question 8

How can PUD present if complication presents?

Answer 8

• Haematemesis
• Perforation
• Gastric outlet obstruction

Question 9

What is Zollinger Ellison syndrome?

Answer 9

• Triad of - severe PUD, gastric acid hypersecretion, gastrinoma
• Gastrin level >1000pg/ml = classic
• 1/3 discovered as part of MEN 1 - pancreas, pituitary, parathyroid tumours
• = investigations for MEN needed

Multiple endocrine neoplasia

Question 10

Bedside and bloods for suspected PUD

Answer 10

• Non-invasive h-pylori testing eg carbon 13 urea breath test or stool antigen test

Question 11

Imaging for PUD

Answer 11

Endoscopy warranted if red flag symptoms:
* New onset dysphagia
* Age over 55 with weight loss and either upper abdominal pain, reflux or dyspepsia
* New onset dyspepsia not responsive to PPI

OR if not responding to emperical treatment

Question 12

What can happen during endoscopy?

Answer 12

• Can biopsy ulceration and send to histology
• Rapid urease test (CLO test) to determine if h-pylori present
• Rpt endoscopy after PPI treatment to check resolution

Question 13

Conservative management PUD

Answer 13

• Smoking cessation
• Weight loss
• Reduce alcohol consumption
• Avoid NSAIDs

Question 14

Pharmacological management PUD

Answer 14

• PPI for 4-6 weeks
• Then reassess for resolution of symptoms
• If h-pylori +ve –> triple therapy

Question 15

Triple therapy for h-pylori

Answer 15

Varies between trusts but usually:
* PPI
* + oral amoxicillin
* + oral clarithromycin OR metronidazole

Question 16

Surgery for PUD?

Answer 16

• If severe or relapsing
• Partial gastrectomy or selective vagotomy

vagotomy = one or more branches of the vagus nerve are cut

Question 17

Complications of PUD

Answer 17

• Bleeding
• Perforation
• GOO