1/ Definition of peptic ulcer disease
- Ulceration of the oesophageal, gastric or duodenal mucosa
2/ Definition of Helicobacter pylori (H.pylori)
- Gram-negative bacterium found in the stomach and associated with the development of peptic ulcer disease and gastric cancer
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3/ Peptic ulcer disease Epidemiology
- 1-2/1000 per year. Previously much more common in men, now roughly equal.
- Duodenal ulcers 4 x more common than gastric ulcers
4/ Helicobacter Pylori Infections
- Prevalence approximately 30% young adults
- Much higher in older people
5/ Causes of peptic ulcer disease
1- H. Pylori (approximately 80%)
- Risk factor for:
- Peptic ulcer disease
- Gastric cancer (six-fold increased risk)
- MALT lymphoma (which may regress if H.Pylori is treated)
- See ‘complications of H.Pylori’ section below for full list of H.Pylori associations
2- Drugs
- Aspirin
- NSAIDs
- Steroids
3-Smoking
4- Alcohol
5- Stress
- Curling’s ulcer (burns – sloughing of mucosa due to plasma loss)
- Cushing’s ulcer (raised intracranial pressure – changes to vagal tone)
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6- Acid hypersecretion
- Zollinger-Ellison – gastrin-secreting tumour (gastrinoma)
- Responsible for 1/1000. Multiple ulcers.
- Treat with high-dose PPI (or curative resection)
- Small bowel resection (loss of negative feedback on acid secretion)
- Systemic mastocytosis (increase histamine production)
7- Abnormal gastric emptying
- Too fast can give duodenal ulcers
- Too slow can cause gastric ulcers and succussion splash
6/ Sign and Syptoms of peptic ulcer disease
Symptoms:
- Heartburn
- Dyspepsia (burping, distension, bloating) – either before or after meals
- Symptoms relieved by antacids
- Pain
- Epigastric
- Posterior in a posterior ulcer
- Haematemesis or melaena
- Anterior duodenal ulcers tend to bleed, posterior ulcers are more likely to perforate than anterior ulcers
- ALARM symptoms (see dyspepsia section)
Signs:
- Sometimes epigastric tenderness
- Succussion splash if gastric emptying delayed
7/ Management of peptic ulcer disease and H. pylori infection.
- Lifestyle advice
- Weight loss; smoking cessation; avoid precipitants; raise the head of the bed; don’t eat late at night
- Stop NSAIDs / bisphosphonates / steroids
- Use of antacids (eg. Gaviscon, Peptac) PRN.
- Trial of full-dose proton pump inhibitor (PPI) for 4-8 weeks for patients with GORD symptoms.
- Offer H2 blocking therapy therapy (e.g. Ranitidine 150mg once to twice daily) if inadequate response to PPI.
- Test for Helicobacter pylori (H. pylori) if symptoms persist (see below for testing methods):
- Treat H. pylori if positive or if endoscopic evidence of PUD
- Eradication therapy
- Amoxicillin 1g twice daily and Clarithromycin 500mg twice daily plus full-dose PPI for 7 days.
- If allergic to penicillin then substitute Clarithromycin 250mg and Metronidazole 400mg both twice daily.
- Upper GI endoscopy if symptoms persist despite above
- Urgent (within 2 weeks) upper GI endoscopy if:
- ALARMS symptoms present
- Age < 55
- High risk i.e. previous gastric surgery; FHx gastric malignancy
8/ Complications of PUB and H. pylori
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- Haemorrhage:
- Controlled endoscopically
- Adrenaline, diathermy, laser coagulation, heat probe.
- Bleeding ulcer base can be undersewn by surgeons
- Perforation:
- Conservative approach (NBM, NG, IV antibiotics) can prevent surgery in up to 50%, if no generalised peritonitis present
- Laparoscopic repair of hole
- Pyloric stenosis (late complication – lots of vomiting):
- Balloon dilatation + PPIs
- If ineffective, drainage procedure (e.g. pyloroplasty)
- MALT lymphoma:
- B-cell
- Metastases are rare
- Associated with paraproteins and pseudohyponatraemia
- H.Pylori eradication leads to regression in 80%
- Gastric cancer:
- VacA and CagA strains of H pylori appear to be associated with an increased risk of gastric cancer
9/ Prognosis
- Approximately 2% recurrence rate
- Smoking, ETOH, NSAIDs increases recurrence rate (especially gastric ulcers)
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