Peptic Ulcer Disease (PUD) Flashcards Preview

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Flashcards in Peptic Ulcer Disease (PUD) Deck (13)
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1

What is a peptic ulcer?

Peptic Ulcer Disease (PUD)

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

Most occur in the stomach or proximal duodenum

2

What is the epidemiology of PUD?

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

3

Outline the basic physiology of acid secretion in the stomach

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)

4

Outline the protective mechanisms of the stomach for acid

  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

5

What is the aetiology & pathophysiology of PUD?

  • 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

6

Outline the classifications of peptic ulcers

Modified Johnson classification;

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

7

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

  • 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?

8

Helicobacter pylori;

  • What
  • Pathologies
  • Diagnosis
  • Management

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

9

What are the investigations for suspected PUD?

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

10

How do you manage PUD medically?

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

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

11

Outline the indications for surgery in PUD

What operations are viable?

  • 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)

12

Outline possible complications of PUD

  • 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

13

Outline Zollinger-Ellison syndrome

  • Definition
  • Variants
  • Tumour location
  • Presentation

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