Peptic Ulcer Disease (PUD and gastritis)

Question 1

what is a typical presentation of peptic ulcer disease and gastritis?

Answer 1

pain relation to eating and epigastric tenderness gastritis: epigastric pain , bloating and belching

Question 2

what are the key differences between peptic and duodenal ulcer?

Answer 2

Question 3

define peptic ulcer disease?

Answer 3

Break in the epithelium lining of the STOMACH or DUODENUM ​

Question 4

what are the causes of peptic ulcer disease and gastritis?

Answer 4

• Helicobacter pylori (chronic) - gram negative flagellate - implicated in 90% of duodenal ulcers and 80% of gastric ulcers.
• NSAIDs (acute) - more commonly causes gastric ulcers - remember to always give PPI with it or ask them to take with meals
• Alcohol (acute)
• Bisphosphonates
• Smoking (acute)

Question 5

state a rare cause peptic ulcer disease and gastritis?

Answer 5

Zollinger-Ellison syndrome (a condition in which a gastrin-secreting tumour or hyperplasia of the islet cells in the pancreas cause overproduction of gastric acid, resulting in recurrent peptic ulcers)

To investigate this: fasting serum gastrin is measured and secretin test. To treat: PPI + tumour resection

Question 6

summarise the epidemiology of peptic ucler disease?

Answer 6

COMMON

Annual incidence: 1-4/1000

More common in males

Mean age: Gastric ulcers: 50s

Helicobacter pylori is usually acquired in childhood and prevalence is roughly equal to age Kin year

Question 7

what are the presenting symptoms of peptic ulcer disease and gastritis?

Answer 7

Epigastric pain

Relieved by antacids

Symptoms have a variable relationship to food intake:

Gastric - pain is worse soon after eating

Duodenal - pain is worse several hours after eating

Patients may present with complications e.g. haematemesis, melaena

Question 8

what are the signs of peptic ulcer disease and gastritis on physical examination?

Answer 8

There may be NO physical findings

Epigastric tenderness

Signs of complications e.g. anaemia

Question 9

what are the appropriate investigations for peptic ulcer disease and gastritis?

Answer 9

If < 55 and no red flags

• H pylori breath test/stool antigen test
• FBC
• Stool occult blood test
• Serum gastrin - zollinger Ellison syndrome

If > 55 or red flags present or treatment fails

• Upper GI endoscopy + biopsy (biopsy for gastric ulcers mainly to rule out malignancy)
• If ulcer is present: repeat endoscopy 6-8 weeks after treatment to confirm resolution and exclude malignancy

Blood- FBC-> LOOK FOR ANAEMIA

Question 11

what is the acute management for peptic ulcer disease?

Answer 11

Fluid resuscitation needed if the ulcer is perforated or bleeding (IV colloids/crystalloids)

Close monitoring of vital signs

Endoscopy

Surgical treatment

NOTE: patients with upper GI bleeding should be treated with IV PPIs at presentation until the cause of bleeding is identified

Question 12

If the ulcer is bleeding, how can haemstasis be acheived?

Answer 12

Injection sclerotherapy

Laser coagulation

Electrocoagulation

Surgery: Indicated if the ulcer has perforated or if the bleeding ulcer can’t be controlled

Question 13

what is the management for H pylori eradication?

Answer 13

Triple therapy for 1-2 weeks

Various combinations may be recommended - usually a combination of 2 antibiotics + PPI (high dose) (e.g. clarithromycin 500mg + amoxicillin 1g/metronidazole 400mg + omeprazole) - taken twice daily

Question 14

what is the management if the peptic ulcer disease is not associated with H pylori?

Answer 14

Treat with PPIs (e.g. lanzoprazole) or H2 antagonists (e.g. ranitidine)

Stop NSAID/bisphosphonates use

Use misoprostol (prostoglandin E1 analogue) if NSAID use is necessary

Question 15

What should you do if the peptic ulcer is consistent for 6 months despite treatment?

Answer 15

surgery due to risk of complications- can inject adrenaline into ulcer and clip endoscopically

Question 16

what are the possible complications of peptic ulcer disease?

Answer 16

Haemorrhage (haematemesis (coffee-ground), melaena, iron-deficiency anaemia)

• Endoscopy - adrenaline injection (1:10,000)
• May need IV PPI
• Maybe need a blood transfusion

Perforation – more commonly seen with duodenal (anterior and superficial parts)

• Sudden sever epigastric pain which rad to shoulder, V and shock signs
• Seen as air under diaphragm - pneumoperitoneum
• NBM and AB
• Endoscopy - first line treatment: adrenaline injection into bleeding site or clip application
• If fails then cover with omental plug (surgical repair)
• IV PPI may be needed later

Obstruction/pyloric stenosis (due to scarring, penetration, pancreatitis)

• Pyloric stenosis - more in children
• Cancers - more in elderly
• V (undigested food), abdo distention, weight loss, malaise lethargy , met alkalosis
• Resus, NG tube, endoscopy/surgical intervention

Question 17

how is haemorrhage as a complication of peptic ulcer treated? and what are the symptoms?

Answer 17

(haematemesis (coffee-ground), melaena, iron-deficiency anaemia)

Endoscopy - adrenaline injection (1:10,000)

May need IV PPI

Maybe need a blood transfusion

Question 18

what are the symptoms of a perforated peptic ulcer and how is it treated?

Answer 18

• Sudden sever epigastric pain which rad to shoulder, V and shock signs
• Seen as air under diaphragm - pneumoperitoneum
• NBM and AB
• Endoscopy - first line treatment: adrenaline injection into bleeding site or clip application-> if fails then cover with omental plug (surgical repair)
• IV PPI may be needed later

Question 19

summarise the prognosis of peptic ulcer disease?

Answer 19

Overall lifetime risk = 10%

Outlook is generally good because peptic ulcers associated with H. pylori can be cured by eradication