GIT 4th PUD 2016.

PEPTIC ULCER DISEASE

Professor Dr. M SHEKHANI

MBChB-CABM-FRCP-EBGH

AETIOLOGY

Contents

DEFINITION

PATHOPHYSIOLOGY

PREDISPOSING FACTORS

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2

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4

MANAGEMENT

Contents

D.DIAGNOSIS

DIAGNOSTIC WORK-UP

MEDICATIONS LIST

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• Mucosal defect in the lower oesophagus, stomach or duodenum, in the jejunum after surgical anastomosis to the stomach or, rarely, in the ileum adjacent to a Meckel’s diverticulum..

Definition:

Epidemiology:• M/F for DU 5:1 - 2:1, GU 2:1 or less. • Chronic gastric ulcer is usually single; 90% on the lesser

curve within the antrum or body-antral junctio. • Chronic DU usually occurs in D1 just distal to the pyloric;

50% on anterior. • GU/DU coexist in 10% • > 1 PU is found in 10–15%.

Pathophysiology

H Pylori

NSAIDs

Smoking

9O% DU,70% GU.In DU infect D cells leading to hypergastrinemia&hyperacidity.

30%;Impair mucosal defence through inhibiting PGs.

> Complication & < healing.

HP>90% DU>70% GU

Smoking NSAIDs

H Pylori: in > 50% of gen population

?Genetics Rarely ZES

Pathophysiology: How HP produces PUD.

NSAIDs use.

cagA

vacA

Adhesins (BabA)&(o

ipA)

•IL-1β expression

•Smoking

Bacterial factors:

Host genetic polymorphisms:

Clinical features:

Poor predictors of PUDPresence.

40%vomiting

30% atypical

In some

Symptoms

R/Rs

Daily vomiting? GOO

Elderly on NSAIDs: unease;anorexia

Asymptomatic present with complications as GIB, Perforation.

Investigations:

Endoscopy

1. For DU not needed because mostly benign except for HP diagnosis or if giant or atypical features( Crohns,TB,Lymphoma,cancer).

2. For GU needed BZ may be malignant.

HP test

Endoscopic biopsy:

90%: Pan head or duodenum

50% multiple

½-2/3 malignant but slow growing

20-60% part of MEN1

Diagnosis: Serum gastrin 10-1000 fold increase& paradoxical inc with secretin. Localization by: EUS& SST Rec scintigraphy.

Features:Short historyComplicated more.Ulcers> in unusual sites, D2,Jej,eso.Unresponsive to trt.Recurs after surgery.Diarrhea in 50%.

Diagnosis:

ZES:Gastrinoma

Drugs for PUD:

Acid suppresants:

PPI/H2RAs/Antacids

Mucosal resistance enhancers

Both:

Sucralfate/Carbinoxolone.

Prpstaglandins.

B05:1• 1.Peptic ulcers occurs in the following sites except:• A.Esophagus.• B.Gastrojejunostomy stoma.• C.Adjacent to Mickel’s diverticulum.• D.Rectum.• E.Duodenum.

B05:2• 2.Peptic ulcers disease behavior in Zollinger Ellison

syndrome characterized by all except:• A.Associated with diarrhea.• B.Occurs in unusual sites.• C.Responds poorly to PPI.• D.Less complicated.• E.Recurs after surgery.

B05:3• 3.Peptic ulcers disease behavior in elderly

characterized by all except:• A.Higher incidence.• B.Higher mortality.• C.Higher admission rates.• D.Lower H Pylori prevalence.• E.More NSAIDs-related.

B05:4• 4.Peptic ulcers disease behavior in elderly

characterized by all except:• A.Atypical pain.• D.Dyspepsia frequently absent .• C.Presentation with complications for the first time.• C.Lower NSAIDs –related.• D.Needs intesive care if complicated.

B05:5• 5. The first step in the pathogenesis of H Pylori-

related PUD is:• A.Depletion of antral D cells.• B.Hypergastrinemia.• C.Hyperacidity.• D.Mucous depletion.• E.Bicarbonate depletion.

B05:6• 6. Host factors in the pathogenesis of PUD include

all except:• A.Interleukin expression.• B.Smoking.• C.NSAIDs use.• D.Alcohol.• E.Genetics.

B05:7• 7. The following are virulant factors of H Pylori

infection except:• A.Cag A.• B.Vac A.• C.Bab A.• D.OIP A.• E.Urease.

B05:8• 8. The factor responsible for survival of H Pylori in

the acidic medium of stomach is:• A.Cag A.• B.Vac A.• C.Bab A.• D.OIP A.• E.Urease.

B05:9• 9. The Duration of most anti H Pylori drug regimens

is:• 7-10 days.• A.7 days.• C.10-20 days.• D.10-14 days.• E.30 days.

B05:10• 10. All anti H Pylori drug regimens should contain:• A.PPIs.• B.Metronidazole.• C.Clarithromycin.• D.Amoxil.• E.Rifabutin.

B05:11• 11. The organisms linked to PUD include all except:• A.H Pylori.• B.HSV.• C.CMV.• D.EBV.• E.H Helmani.

B05:12• 12. Indications for H Pylori eradication include all

except:• A.PUD.• B.MALTOMA.• C.Dyspepsia in youngs without red flags.• D.Curative-intend trteated gastric cancer.• E.Family history of gastric cancer.

B05:13• 13. The ideal drug for treating PUD is:• A.PPI.• B.H2RAs.• C.Misoprostol.• D.Bismuth.• E.Sucralfate.