Peptic Ulcers

Question 1

Helicobacter pylori is a

Answer 1

Gram-negative bacteria

Question 2

Helicobacter pylori Associations

Answer 2

peptic ulcer disease
gastric cancer
B cell lymphoma of MALT tissue
atrophic gastritis

Question 3

H pylori seen in ?% of duodenal ulcers, ?% of gastric ulcers

Answer 3

95% of duodenal ulcers, 75% of gastric ulcers

Question 4

B cell lymphoma of MALT tissue - eradication of H pylori results causes regression in ?% of patients

Answer 4

eradication of H pylori results causes regression in 80% of patients

Question 5

Helicobacter pylori mx

Answer 5

eradication may be achieved with a 7 day course of

a proton pump inhibitor + amoxicillin + (clarithromycin OR metronidazole)

Question 6

Helicobacter pylori mx if penicillin allergic:

Answer 6

a proton pump inhibitor + metronidazole + clarithromycin

Question 7

Peptic ulcer disease (uncomplicated) drug associations?

Answer 7

NSAIDs
SSRIs
corticosteroids
bisphosphonates

Question 8

Peptic ulcer disease (uncomplicated) sx

Answer 8

epigastric pain
nausea

duodenal ulcers - epigastric pain when hungry, relieved by eating
gastric ulcers - epigastric pain worsened by eating

Question 9

Peptic ulcer disease (uncomplicated) ix

Answer 9

Helicobacter pylori should be tested for

either a Urea breath test or stool antigen test should be used first-line

Question 10

Peptic ulcer disease (uncomplicated) mx

Answer 10

if Helicobacter pylori is negative then proton pump inhibitors (PPIs) should be given until the ulcer is healed

if Helicobacter pylori is positive then eradication therapy should be given

Question 11

The symptoms of perforation secondary to peptic ulcer disease typically develop slowly

Answer 11

false

suddenly

Question 12

The symptoms of perforation secondary to peptic ulcer disease include?

Answer 12

epigastric pain, later becoming more generalised

patients may describe syncope

Question 13

Peptic ulcer disease (perforation) plain x rays diagnostic

Answer 13

false

diagnosis is largely clinical, UptoDate recommend that plain x-rays are the first form of imaging to obtain

Question 14

Peptic ulcer disease (perforation) An upright (‘erect’) chest x-ray shows

Answer 14

75% of patients with a perforated peptic ulcer will have free air under the diaphragm

Question 15

Bleeding is the most common cause of peptic ulcer disease, account for around three-quarters of problems.

Answer 15

true

Question 16

Which artery can be the source of a significant gastrointestinal bleed occurring as a complication of peptic ulcer disease.

Answer 16

The gastroduodenal artery can be the source of a significant gastrointestinal bleed occurring as a complication of peptic ulcer disease.

Question 17

Peptic ulcer disease (acute bleeding) sx

Answer 17

haematemesis
melaena
hypotension, tachycardia

Question 18

Peptic ulcer disease (acute bleeding) mx

Answer 18

ABC
IV proton pump inhibitor
first-line treatment is endoscopic intervention
if this fails - urgent interventional angiography with transarterial embolization or
surgery

Question 19

Helicobacter pylori: tests
should not be performed within ? weeks of treatment with an antibacterial or within ? weeks of an antisecretory drug (e.g. a proton pump inhibitor)

Answer 19

should not be performed within 4 weeks of treatment with an antibacterial or within 2 weeks of an antisecretory drug (e.g. a proton pump inhibitor)

Question 20

Helicobacter pylori: tests

urea breath test may be used to check for H. pylori eradication

Answer 20

true

Question 21

Helicobacter pylori: tests

Rapid urease test (e.g. CLO test) describe

Answer 21

biopsy sample is mixed with urea and pH indicator

colour change if H pylori urease activity

Question 22

Helicobacter pylori: tests
Serum antibody
remains positive after eradication

Answer 22

true

Question 23

Helicobacter pylori: tests Gastric biopsy describe

Answer 23

provides histological evaluation alone, no culture

culture of this provide information on antibiotic sensitivity

Question 24

Gastric cancer - Epidemiology

Answer 24

peak age = 70-80 years
more common in east than the West
more common in males, 2:1

Question 25

Gastric cancer - Histology

Answer 25

signet ring cells large vacuole of mucin which displaces the nucleus to one side.

Question 26

Gastric cancer Higher numbers of signet ring cells are associated with a worse prognosis

Answer 26

true

Question 27

Gastric cancer Associations

Answer 27

``` H. pylori infection blood group A: gAstric cAncer gastric adenomatous polyps pernicious anaemia smoking diet: salty, spicy, nitrates may be negatively associated with duodenal ulcer ```

Question 28

Gastric cancer sx

Answer 28

dyspepsia nausea and vomiting anorexia and weight loss dysphagia

Question 29

Gastric cancer ix

Answer 29

diagnosis: endoscopy with biopsy staging: endoscopic ultrasound has recently been shown to be superior to CT

Question 30

Tumours of the gastro-oesophageal junction are classified as

Answer 30

Type 1 - True oesophageal cancers and may be associated with Barrett's oesophagus. Type 2 Carcinoma of the cardia, arising from cardiac type epithelium or short segments with intestinal metaplasia at the oesophagogastric junction. Type 3 Sub cardial cancers that spread across the junction. Involve similar nodal stations to gastric cancer.

Question 31

Gastric cancer staging ix

Answer 31

``` CT scanning of the chest abdomen and pelvis is the routine first line staging investigation in most centres. Laparoscopy to identify occult peritoneal disease PET CT (particularly for junctional tumours) ```

Question 32

Gastric cancer Treatment Most patients will receive chemotherapy either pre or post operatively.

Answer 32

true

Question 33

Gastric cancer mx

Answer 33

Proximally sited disease greater than 5-10cm from the OG junction may be treated by sub total gastrectomy Total gastrectomy if tumour is <5cm from OG junction

Question 34

Gastric cancer mx | type 2 junctional tumours

Answer 34

oesophagogastrectomy is usual

Question 35

Gastric cancer prognosis - Percentage 5 year survival

Answer 35

``` All RO resections 54% Early gastric cancer 91% Stage 1 87% Stage 2 65% Stage 3 18% ```

Question 36

Zollinger-Ellison syndrome is

Answer 36

ondition characterised by excessive levels of gastrin, usually from a gastrin secreting tumour usually of the duodenum or pancreas

Question 37

Zollinger-Ellison syndrome is associated with MEN IIB

Answer 37

false | Around 30% occur as part of MEN type I syndrome

Question 38

Zollinger-Ellison syndrome features

Answer 38

multiple gastroduodenal ulcers diarrhoea malabsorption

Question 39

Zollinger-Ellison syndrome diagnosis

Answer 39

fasting gastrin levels: the single best screen test | secretin stimulation test

Question 40

Acute upper gastrointestinal bleeding | which scores to use and when?

Answer 40

use the Blatchford score at first assessment, and | the full Rockall score after endoscopy

Question 41

Blatchford score looks at

Answer 41

``` Urea (mmol/l) Haemoglobin (g/l) Systolic blood pressure (mmHg) Pulse >=100/min = 1 Presentation with melaena = 1 Presentation with syncope = 2 Hepatic disease = 2 Cardiac failure = 2 ```

Question 42

Patients with a Blatchford score of 0 may be considered for early discharge.

Answer 42

true

Question 43

Acute upper gastrointestinal bleeding if actively bleeding transfuse with?

Answer 43

platelet transfusion

Question 44

Acute upper gastrointestinal bleeding if actively bleeding when to transfuse with FFP

Answer 44

fibrinogen level of less than 1 g/litre, or a prothrombin time (international normalised ratio) or activated partial thromboplastin time greater than 1.5 times normal

Question 45

Acute upper gastrointestinal bleeding if actively bleeding when to transfuse with prothrombin complex concentrate?

Answer 45

patients who are taking warfarin and actively bleeding

Question 46

Endoscopy | should be offered immediately after resuscitation in patients with a severe bleed

Answer 46

true | Within 24 hrs

Question 47

Acute upper gastrointestinal bleeding | Management of non-variceal bleeding PPIs before endoscopy

Answer 47

false NICE do not recommend the use of proton pump inhibitors (PPIs) before endoscopy to patients with suspected non-variceal PPIs should be given to patients with non-variceal upper gastrointestinal bleeding and stigmata of recent haemorrhage shown at endoscopy

Question 48

Acute upper gastrointestinal bleeding | Management of non-variceal bleeding

Answer 48

PPIs should be given to patients with non-variceal upper gastrointestinal bleeding and stigmata of recent haemorrhage shown at endoscopy if further bleeding - repeat endoscopy, interventional radiology and surgery

Question 49

Acute upper gastrointestinal bleeding Management of variceal bleeding at presentation

Answer 49

terlipressin and prophylactic antibiotics should be given to patients at presentation (i.e. before endoscopy)

Question 50

Acute upper gastrointestinal bleeding Management of variceal bleeding for patients with gastric varices

Answer 50

injections of N-butyl-2-cyanoacrylate for patients with gastric varices transjugular intrahepatic portosystemic shunts (TIPS) should be offered if bleeding from varices is not controlled with the above measures

Question 51

Acute upper gastrointestinal bleeding Management of variceal bleeding for oesophageal varices

Answer 51

band ligation should be used for oesophageal varices transjugular intrahepatic portosystemic shunts (TIPS) should be offered if bleeding from varices is not controlled with the above measures