PUD & Dyspepsia

Question 1

What is dyspepsia?

Answer 1

Complex symptoms of the upper GI tract.

Question 2

What are the symptoms of dyspepsia?

Answer 2

Upper abdominal pain, acid reflux, heartburn, nausea, vomiting and bloating

Question 3

What are the alarm symptoms of dispepsia?

Answer 3

Unexplained weight loss, vomiting, pain on swallowing, GI bleeding

Question 4

Describe the management pathway for dyspepsia

Answer 4

• Meds check - NSAIDs?
• OTC antacids, alginate - immediate relief
• PPI and H2RA

Question 5

What are the causes of dyspepsia?

Answer 5

GORD
PUD
Non-ulcer dyspepsia - H pylori, delayed gastric emptying
Zollinger-Ellison syndrome
Malignancy/ cancer

Question 6

DList lifestyle modifications for dyspepsia

Answer 6

Small frequent meals
Stop smoking
Reduce alcohol intake
Reduce caffeine
Review meds

Question 7

What is an Ulcer?

Answer 7

A lesion on epithelial surface caused by superficial loss of tissue - skin/mucous membrane

Question 8

What are peptic ulcers?

Answer 8

• Ulcer in the alimentary tract - stomach/ duodenum
• Deep enough to penetrate the muscularis mucosa
• Cause: increase acid and pepsin in gastric juice

Question 9

What are the major causes of PUD?

Answer 9

H pylori and NSAIDs

Question 10

What are the 2 types of PU?

Answer 10

Duodenal and gastric ulcers

Question 11

Describe duodenal ulcer

Answer 11

Caused by increased acid in the duodenum
- Increased parietal cells
- Increased gastrin secretion
- Decreased acid secretion inhibition and decreased HCO3 secretion - H pylori
- Genetic and smoking harming gastric mucosal healing

Question 12

Describe gastric ulcer

Answer 12

Breakdown of gastric mucosa
- gastritis - inflammation of stomach
- H pylori release cytokines
- Abnormal mucus production
- Parietal cell damage - low acid production

Question 13

What are the investigations that need to be carried out?

Answer 13

Symptoms of dyspepsia
Endoscopy for peptic ulcers - invasive and expensive
Radiology - less specific
H pylori detection - 13C urea breath test - non-invasive/ more accurate. Urease activity dependant - urea hydrolysed by urease caused by H pylori making 13CO which detected in breath

Question 14

How do NSAIDs damage mucosal layer?

Answer 14

• Superficial erosions which leads to haemorrhages
• Erosions caused by inhibitions of COX enzymes in mucosal cells.
• Enteric coating doesn’t reduce risk of ulcers but lowers superficial damage.
• Decreases production of protective prostaglandins in mucosal cells - acid damage

Question 15

PPIs

Answer 15

Inhibit the H/K ATPase which responsible to acid secretion from parietal cells. Binds to -SH and stops H from getting secreted which decreased acid secretion
EXAMPLE: Omeprazole

Question 16

H2RAs

Answer 16

Antagonise histamine which decrease acid secretion
EXAMPLE: Cimetidine, Famotidine

Question 17

Anticholinergics

Answer 17

Block ACh in parietal cells

Question 18

Miscellaneous

Answer 18

Bismuth chelate
Sucralfate
Misoprostol
Antacids

Question 19

What is H pylori?

Answer 19

Gram negative spiral bacterium
- Increases risk of gastric cancer with time

Question 20

How does H pylori lead to ulcers?

Answer 20

• Produces cytotoxins associated gene A - CagA
• Activate the inflammatory cascade
• Produces urease, neuraminidase and haemolysis
• Increase gastric/acid secretion

Question 21

Describe the mechanism of destruction of cells in regards to H pylori

Answer 21

• Penetrate the mucous layer
• Release urease to neutralise mucousal layer and form ammonia
• This leads to exposure of endothelial cells to acids
  ALSO: caused by release of inflammatory cells

Question 22

How is H pylori diagnosed?

Answer 22

Invasive test: Rapid urease test (RUT), Culture, Histology, Polymerase (PCR).
Non-invasive test: urea breath test, serological, stool antigen test

Question 23

What is the treatment pathway for H pylori?

Answer 23

OCA- omeprazole, clarithromycin, amoxicillin - PAC 500
OCM - omeprazole, clarithromycin, metronidazole - PAC 250 - cheaper