Peptic Ulcer Disease

This is the ulceration of mucosa in the lower oesophagus, stomach, or duodenum. The most common cause of oesophageal ulcers is GORD. The causes of gastric/duodenal ulcers are:

• Weakening of protective layer - Due to NSAIDs and H. pylori

• Increased gastric acid due to Stress, Alcohol, Smoking, Caffeine, Zollinger-Ellison syndrome

Patients present with:

• Epigastric pain/discomfort

• Dyspepsia (bloating, heartburn, belching, pain)

• N+V

• Haematemesis/melaena if acute bleeding

• Anaemia if chronic bleeding

The main way to differentiate a gastric ulcer from a duodenal ulcer is that the pain from a gastric ulcer is worsened by eating, whereas the pain from a duodenal ulcer is improved by eating.

N.B. When eating, the pylorus constricts, which is why the pain presents differently with the location of the ulcer.

Investigations

Main investigation to do is an Endoscopy with a Rapid Urease test (for H. pylori) and Biopsy (exclude malignancy) done.

N.B. Urea breath test can also be done. Solution of urea is swallowed and the patient breathes back out. The amount of CO2 is measured as the H. pylori bacteria produces Urease to break down the urea.

Management

Conservative:

• Weight loss

• Less alcohol, smoking, caffeine, stress

• Have more regular, smaller meals

• Avoid eating late night (3+ hrs before)

• Avoid acidic foods, fatty or spicy foods

Medical:

• H. pylori -ve - 4-8 weeks of full-dose PPI

• H. pylori +ve - Triple therapy of PPI + 2 Abx (Amoxicillin + Clarithromycin)

N.B. Metronidazole can be used if penicillin intolerant.

Complications

• Bleeding - Can be small, chronic bleeds, leading to anaemia. Can also be a large, acute bleed, leading to haematemesis/melaena.

• Perforation - Leads to acute abdomen and peritonitis

• Stricture formation due to fibrotic healing - Can present as an obstruction

• Malignancy - Rare development of cancer from a peptic ulcer