What is affected by peptic ulcer disease
Any acid affected site:
Oesophagus
Stomach
Duodenum
What are the causes of PUD
High acid secretion
Loss of ability to defend against acid attacks
Describe how high acid secretion causes PUD
Upregulation of gastrin produces acid secretion long after food stimulation is gone
The excess acid causes ulcers to develop
Describe how normal levels of acid secretion can lead to PUD
There may be a reduced protective barrier to the stomach lining
The thin layer of mucus can be removed by drugs such as NSAIDS or steroids, but also by the bacteria Heliobacter pylori
What is a peptic ulcer
A burn which burns deep into tissues which may eventually extend through to erode an artery or potentially can go straight through the viscous wall and into the peritoneum - a perforated ulcer
Describe the trend between peptic ulcers and age
Incidence increases up to about age 50 then starts to fall again
Describe how H.pylori can cause a peptic ulcer to form
Bacteria gets into the protective mucous, removes it and allows acid attack and inflammation to happen within the stomach lining
What are the effects of H.pylori
Gastric ulcers
Chronic gastric wall inflammation - lymphoma of the stomach
Why is chronic gastric wall inflammation considered a mucosa associated lymphoid tumour (MALT)
If you remove the cause, the lymphoma will disappear
How is H.pylori eliminated
Triple therapy:
2 antibiotics - usually amoxicillin with metronidazole
1 proton pump inhibitor - usually omeprazole
Given for 2 weeks
What are the signs and symptoms of PUD
Often none
Epigastric burning pain
Signs usually only present when complications are present such as bleeding or perforations
Describe epigastric burning pain
Worse before or just after meals
Worse at night
Relieved by food, alkali and vomiting
What investigations can be carried out for PUD
Endoscopy - allows visualisation of the tissues and a biopsy to be taken to check for H.pylori
Radiology - barium meal
Anaemia - FBC and FOB
H.pylori test - breath, antibodies and mucosa
What systemic complications can be caused by PUD
Anaemia
What local complications can be caused by PUD
Perforation
Haemorrhage
Stricture
Malignancy
Describe the consequences of a haemorrhage caused by PUD
Erosion of the ulcer into a blood vessel will cause bleeding into the stomach leaving a large quantity of blood in the stomach which can be vomited up
It is often brown and granular - coffee ground vomit
If found it should always trigger an endoscopy quickly as there may be a significant vessel bleeding
Describe the consequences of stricture caused by PUD
Stricture may form as the chronic irritation and ulceration heal by secondary intention
If this produces a scar which contracts it can reduce the size of the exit from the stomach
What medical treatments can be carried out for PUD
Smoking cessation
Small regular meals
H.pylori eradication therapy
Ulcer healing drugs - proton pump inhibitors
What surgical treatments can be carried out for PUD and why may they be carried out
Endoscopy - to decide whether a surgical or medical approach is most effective
Surgical excision - excision of the ulcer through a partial gastrectomy - now considered last resort
Vagotomy to reduce acid secretion by dividing the vagus nerve
When should surgical treatment be carried out for PUD
Following an acute event: Stricture Acute bleed Perforation Malignancy
What types of medication can be used to treat PUD
H2 receptor blockers and proton pump inhibitors to reduce acid secretion
Eliminate H.pylori and use prostaglandin inhibitors to improve the mucosal barrier
What must happen after triple therapy
H.pylori must be tested through either endoscopy and biopsy or through breath testing
What different surgeries are available for PUD
Bilroth 1
Bilroth 2
Vagotomy
Describe Bilroth 1 surgery
Allowed excision of part of the stomach and then anastomoses of the duodenum to the remaining part of the stomach
What is the problem with Bilroth 1 surgery
No sphincter from the stomach to the duodenum so food can flow freely
Describe Bilroth 2 surgery
Same stomach excision as Bilroth 1 but instead the stomach empties further down into the duodenum which causes less problems
What is the problem with Bilroth 2 surgery and how is it resolved
Bind loop can cause bacterial proliferation but the pancreatic and biliary secretions still flow into this and keep moving the contents down
Describe a vagotomy
By dividing the branches from the main vagal trunk passing into the stomach wall, the acid secretion caused by the neurological trigger can be reduced
