Peptic ulcer disease and gastritis

PEPTIC ULCER DISEASE

PUD is fairly rare as we have PPIs to treat them and prevent them from occurring. A peptic ulcer is an ulcer that is found within the lining of the stomach/duodenum. Gastric ulcers are in the stomach and are more prominent in the lesser curvature/proximal duodenum (in older patients), while duodenal ulcers are in the duodenum and are 4x more common.

The layers of the GI tract are:

1. Epithelial lining
2. Lamina propria
3. Muscularis mucosa
4. Submucosa
5. Muscularis propria

Pathophysiology

The 2 most common causes of peptic ulcers are:

1. ⭐️ Helicobacter pylori - this is the number one cause of duodenal ulcers
2. ⭐️ NSAIDs

Other causes are: stress, gastric bypass surgery, Zollinger-Ellison syndrome (a rare syndrome where we have excessive production of gastrin due to an endocrine tumour or gastrinoma)

🦠

H. Pylori is a gram negative bacteria producing urease to break down urea → CO2 and ammonia (NH3). The ammonia neutralises the gastric acid to allow for an alkaline environment in which the bacteria can proliferate and damage epithelial cells → inflammation, ulceration, neoplasia. We can diagnose an infection with a urea breath test or rapid urease test (during endoscopy). They may be followed up with a urea breath test to assess if the bacteria has been cleared (this is the only test recommended to assess eradication. Other tests include a stool antigen test and serum antibody. It can be treated with triple therapy of: PPI + clarithromycin + amoxicillin/metronidazole for 7 days.

⚠️ It is important to inform patients to abstain from alcohol when taking metronidazole.

😷 Presentation

1. Gastritis
2. Epigastric/retrosternal pain - during or shortly after eating gastric ulcers may get worse. However, duodenal ulcers may be worse when hungry and relieved by eating.

🔍 Investigations

😮‍💨

Carbon-13 urea breath test is used for H. Pylori Antibodies against H. Pylori may also be used along with a stool antigen test

📷

Elderly patients and any patient with red flag symptoms should have an OGD done.

NICE recommends referral for urgent OGD in patients with new-onset dysphagia or if they are aged >55 years old with weight loss and upper abdominal pain/reflux/dyspepsia.

🧰 Management

🔪

Surgical management

1. Billroth I - if there is a pyloric ulcer or duodenal ulcer.
2. Billroth II - for an ulcer in the fundus or a large ulcer in the stomach.
3. Vagotomy - removal of branches of the vagus nerve to reduce stimulation of the PSNS for gastric acid secretion

🚨 Complications

• Perforation - erect chest x-ray is a key initial investigation for a suspected perforated peptic ulcer as it can demonstrate the presence of free air under the diaphragm- pneumoperitoneum- highly suggestive of perforation. It may present as sudden onset severe abdominal pain.
• Bleeding peptic ulcer - hypotension + melaena → bleeding peptic ulcer.

GASTRITIS

⚠️ Risk factors

😷 Presentation

🔍 Investigations

🧰 Management

1. Lifestyle: ↓ alcohol & tobacco
2. H. pylori eradication: triple therapy
3. Drugs to reduce acid: PPI’s
4. Drug-induced ulcers: stop drug if possible.