Peptic Ulcer Disease (PUD)

Question 1

What is a peptic ulcer?

Peptic Ulcer Disease (PUD)

Answer 1

An ulcer of the mucosa in or adjacent to an acid-bearing area

Most occur in the stomach or proximal duodenum

Question 2

What is the epidemiology of PUD?

Answer 2

• Dyspepsia - 40% of pop annually
• Duodenal ulcers (DUs) are 3x more common than Gastric ulcers (GUs)
• 15% of the population
• Common in elderly

Question 3

Outline the basic physiology of acid secretion in the stomach

Answer 3

H+ released by Parietal cells (in crypts in fundus)

Stimulated by;

• Histamine (from ECL cells)
• Gastrin (from G cells stim. by AA)
• ACh (from parasympathetic)

Inhibited by;

• Somatostatin inhibits ACh (from D cells stim. by low pH)

Question 4

Outline the protective mechanisms of the stomach for acid

Answer 4

1. Regulation of acid
   
   • Somatostatin (from D cells when low pH) inhibits Ach
2. Mucosal barrier
   
   • Apical surface resistant to low pH
   • Gastric surfactant (blocks polar ions)
   • Mucin
3. Epithelial repair is remarkably quick
   
   • Damage → Hyperemic → Mucoid cap → Growth

Question 5

What is the aetiology & pathophysiology of PUD?

Answer 5

• Helicobacter pylori (gram- bacteria)
  
  • Dec gastric mucosal resistance (GUs)
  • Inc gastric acid secretion (DUs)
• NSAIDs (Aspirin)
  
  • Inhibit COX ⇒ dec. prostaglandins (which provide mucosal protection)
  • Cytotoxic to epithelial layer
• Inc gastric acid secretion due to;
  
  • Inc gastrin secretion
  • Inc parietal cell mass
  • Decreased somatostatin production due to antral gastritis
• Disruption of mucous protective layer
• Reduced duodenal bicarbonate production
• Production of virulence factors:
  
  • Vacuolating toxin (Vac A)
  • Cytotoxic associated protein (CagA)
  • Urease
  • Adherence factors

Question 6

Outline the classifications of peptic ulcers

Answer 6

Modified Johnson classification;

1. Body & fundus of stomach (gastric)
2. Body & duodenal (gastric & duodenal)
3. Pyloric channel
4. Proximal gastroesophageal ulcer

Question 7

What are the clinical features of Peptic Ulcer Disease (PUD)?

Answer 7

• Bruning epigastric pain
  
  • Related to hunger, eating specific foods or time of day
• Bloating +/- fullness after meals
• Heartburn (retrosternal pain with demonstrable acid reflux)
• Haemorrhage
• ALARM Symptoms
  
  • Anaemia (iron deficiency)
  • Loss of weight
  • Anorexia
  • Recent onset of progressive symptoms
  • Melaena or haematemesis
  • Swallowing difficulty

Signs;

• Tender epigastrium (non-specific)
• Any abdo mass; supraclavicular nodes +/- hepatomegaly?

Question 8

Helicobacter pylori;

• What
• Pathologies
• Diagnosis
• Management

Answer 8

What

• Gram -ve urease-producing spiral-shaped bacterium
• Found in gastric antrum and in areas of gastric metaplasia

Pathologies

• Chronic active gastritis
• PUD
• Gastric cancer
• Gastric B cell lymphoma

Diagnosis

• Non-invasive
  
  • ¹³C-urea breath test
    
    • Hydrolysis of ingested ¹³C-urea by H. pylori to produce ¹³C expired in air
  • Stool antigen test
  • Serology; serum antibody detection (lower spec & sens)
• Invasive
  
  • Rapid urease (CLO) test
    
    • Urease from H. pylori breaks down urea to produce ammonia causing a pH-dependent colour change in the indicator present
  • Histology
    
    • Direct visualization of the organism

Management, triple therapy

1. Omprezole - PPI
2. • metronidazole/ amoxicillin - antibiotic
3. • clarithromycin/ erythromycin - antibiotic

Question 9

What are the investigations for suspected PUD?

Answer 9

Diagnosis;

• Test for H. pylori (¹³C breath test)
• Gastroscopy endoscopy (visualisation, biopsy)
• Barium meal
• Relieved by anti-acid? (PPI’s, H2 receptor antagonists)
• Relieved on stopping NSAIDs?
• CT if perforation suspected

Question 10

How do you manage PUD medically?

Outline the treatments for H. Pylori, NSAID and other causes

Answer 10

Medical

• Alcohol, smoking, avoid NSAIDs
• PPIs
  
  • Omeprazole 20mg PO od
  • Lansoprazole
• H2 blockers (if intolerant)
  
  • Ranitidine 150mg PO bd
  • Cimetidine 400mg PO bd
• Topical antacids
  
  • Gaviscon

H. pylori induced

• Treat H. pylori - triple therapy
  
  • Omprezole
  • • metronidazole/ amoxicillin
  • • clarithromycin

Aspirin/ NSAID induced

• Stop NSAIDs
• Medical treatment

Other

• ​Medical treatment
• Endoscopy/ biopsy to exclude malignancy?

SURGERY

Question 11

Outline the indications for surgery in PUD

What operations are viable?

Answer 11

• Intractable
• Perforation
• Obstruction (pyloric stenosis)
• Gastric cancer risk
• Peripyloric ulcer

Operations (gastrectomy’s)

• Billroth 1 (remove antrum, join to duodenum)
• Billroth 2/ Polya (remove antrum, join to jejunum)

Question 12

Outline possible complications of PUD

Answer 12

• Perforation
  
  • DUs>GUs
  • Surgical closure of perforation and drainage of abdomen
  • H. pylori subsequently eradicated
• Gastric outlet obstruction
  
  • Rare, carcinoma commest cause
  • Due to surrounding oedema & scaring following healing
  • Copious projectile vomiting, succussion splash, metabolic alkalosis,
• Haemorrhage

Question 13

Outline Zollinger-Ellison syndrome

• Definition
• Variants
• Tumour location
• Presentation

Answer 13

Definition

• Endocrinopathy caused by gastrin-secreting tumours
• Cause multiple, refractory, recurrent duodenal PU

Variants

• Sporadic (isolated)
• Multiple endocrine neoplasia type 1 (MEN1) [associated with parathyroid/ pituitary tumours]

Tumour location

• Duodenum (60-65%)
• Pancreas (30%)
• Organs (rare(

Presentation

• MEN1 present early
• PUD symptoms & bleed
• Diarrhoea