Peptic ulcers

Question 1

Classification of peptic ulcers?

Answer 1

Acute: drugs (NSAIDS)
Chronic: drugs, H. pylori, ↑Ca, Zollinger-Ellison

Question 2

Duodonal vs Gastric ulcers

1. pathology
2. Risk factors
3. Presentation

Answer 2

1. D: 4x commoner cf. GU, 1st part of duodenum (cap), M>F
   G: Lesser curve of gastric antrum, Beware ulcers elsewhere (often malignant)
2. D: H. pylori (90%), Drugs: NSAIDs, steroids, Smoking, EtOH, ↑ gastric emptying, Blood group O
   G: H. pylori (80%), Smoking, Drugs, Delayed gastric emptying, Stress (Cushing’s: intracranial disease, Curling’s: burns, sepsis, trauma)
3. D: Epigastric pain (Before meals and at night, Relieved by eating or milk)
   G: Epigastric pain (Worse on eating, Relieved by antacids), Wt. loss

Question 3

Complications of peptic ulcers

Answer 3

I. Haemorrhage: Haematemeis or melaena, Fe deficiency anaemia
II. Perforation: peritonitis
III. Gastric Outflow Obstruction (Vomiting, colic, distension)
IV. Malignancy (↑ risk ̄c H. pylori)

Question 4

Haematemesis

Answer 4

vomiting of blood

Question 5

Zollinger-Ellison

Answer 5

• rare condition in which one or more tumours form in your pancreas or the upper part of your small intestine (duodenum), increased production of gastrin

Question 6

Investigations of peptic ulcers

Answer 6

I. Bloods: FBC, urea (↑ in haemorrhage), Gastrin levels (if Zollinger-Ellison suspected)
II. C13 urea breath test (h pylori)
III. OGD (stop PPIs >2wks before)
- CLO (campylobacter like organism)/ urease test for H. pylori
- Always take biopsies of ulcers to check for Ca

Question 7

Conservative management of peptic ulcer disease?

Answer 7

 Lose wt.
 Stop smoking and ↓ EtOH
 Avoid hot drinks and spicy food
 Stop drugs: NSAIDs, steroids
 OTC antacids

Question 8

Medical management of peptic ulcer disease?

Answer 8

I. OTC antacids: Gaviscon, Mg trisilicate
II. H. pylori eradication: PAC500 or PMC250
III. Full-dose acid suppression for 1-2mo
- PPIs: lansoprazole 30mg OD
- H2RAs: ranitidine 300mg nocte
IV. Low-dose acid suppression PRN

Question 9

H. pylori eradication

Answer 9

PAC 500
PPIS: lansoprazole 30 mg BD
Amoxicillin 1g BD
Clarithromycin 500mg BD

PMC 250
PPIS lanzoprazole 30 mg BD
Metronidazole 400mg BD
Clarithromycin 250mg BD

Question 10

Surgery for peptic ulcer disease

Answer 10

• Secretion stimulated by gastrin and vagus N.
  1. vagotomy
  2. anterectomy + vagotomy
• Distal half of stomach removed + anastomosis: (Directly to duodenum or to small bowel loop)
  3. Subtotal gastrectomy c ̄ Roux-en-Y
  connecting proximal part of stomach to duodenum

Question 11

Physical complications of PUD surgery?

Answer 11

Physical
I. Stump leakage
II. Abdominal fullness
III. Reflux or bilious vomiting (improves  ̄c time)
IV. Stricture

Question 12

Metabolic complications of PUD surgery?

Answer 12

I. Dumping syndrome
- occurs when food, especially sugar enters small bowel too quickly
- Abdo distension, flushing, n/v
- Early: osmotic hypovolaemia
- Late: reactive hypoglycaemia
II. Blind loop syndrome → malabsorption, diarrhoea
- Overgrowth of gut flora bacteria in duodenal stump
- Anaemia: Fe + B12
- Osteoporosis
III. Wt. loss: malabsorption of ↓ calories intake

Question 13

Duodenal stump?

Answer 13

portion of duodenum not removed during gastric surgery