questions 5

Peptic Ulcer Disease

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Topic updated on 12/20/16 8:12pm

Snap Shot
  • A 65-year-old-male presents with complaints of epigastric pain and belching, which improves when he eats food, but gets worse within a few hours after his meal. He said he has noticed a change in the color of his stool.
Introduction
  • Painful sores or ulcers in the lining of the stomach or duodenum
    • breach in the mucosa with extension into the submucosa or deeper 
  • Occurs when gastric acid secretion outweighs mucosal defenses
    • most commonly due to decreased mucosal barrier
      • NSAIDs
      • H.pylori
      • smoking
    • less commonly due to acid hypersecretion
      • such as gastrinoma (Zollinger-Ellison syndrome)
Classification
  • Duodenal ulcers  
    • more common, usually in first part of duodenum
      • typically due to H. pylori, which infects the antrum of the stomach and causes increased acid in the duodenum 
    • low risk of malignancy 
    • caused by acid hypersecretion or ↓ mucosal barrier
  • Gastric ulcers
    • less common, usually in lesser curvature of stomach
    • higher risk of malignancy
    • not caused by acid hypersecretion
Presentation
  • Duodenal ulcer 
    • chronic dull, burning, aching epigastric pain that may radiate to the back
    • improves with meals, but worsens 1-3 hours after eating
    • awaken patient at night
  • Gastric ulcer
    • midepigastric, gnawing pain
    • worse with meals
  • Physical exam
    • ulcer perforations can present with
      • pain in right shoulder 
      • rebound tenderness
      • ileus as a result of chemical peritonitis
      • peritoneal signs secondary to acute perforation
Evaluation
  • H. pylori
    • see Gastritis topic 
  • Upper endoscopy
    • must have biopsy to rule out malignancy in gastric ulcers
    • do not need to biopsy duodenal ulcers
    • non-malignant appearance has "punched-out" margins
    • malignant appearance has raised/irregular margins
  • Serology
    • serum gastrin to rule out Zollinger-Ellison syndrome
Treatment
  • Lifestyle
    • discontinue smoking and NSAIDs
  • Pharmacologic
    • mucosal protectors
      • bismuth
      • sucralfate
      • misoprostol
    • acid control
      • proton pump inhibitors (PPI's) 
      • H2 receptor antagonist 
    • antibiotics
      • eradicate H. pylori
  • Surgical
    • parietal cell vagotomy
      • indicated in refractory duodenal cases
Complications
  • Gastric/duodenal perforations
    • abdominal radiograph will show "air under the diaphgram"
  • Hemorrhage
    • from left gastric artery in gastric ulcers
    • from gastroduodenal artery in duodenal ulcers
  • Gastric outlet obstruction


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Qbank (4 Questions)

TAG
(M1.GI.4) A 41-year-old male who takes NSAIDs regularly for his chronic back pain develops severe abdominal pain worse with eating. Upper endoscopy is performed and the medical student asks the supervising physician how the histological differentiation between a gastric ulcer and erosion is made. Which of the following layers of the gastric mucosa MUST be breached for a lesion to be considered an ulcer? Topic Review Topic

1. Epithelium
2. Epithelium, lamina propria
3. Epithelium, lamina propria, muscularis mucosa
4. Epithelium, lamina propria, muscularis mucosa, and submucosa
5. Epithelium, lamina propria, muscularis mucosa, submucosa, and adventitia

PREFERRED RESPONSE ▶
TAG
(M1.GI.20) A 52-year-old Caucasian male presents to your office complaining of black, tarry stool. Which of the following possible causes of this patient's presentation is LEAST associated with the development of carcinoma? Topic Review Topic

1. Barrett's esophagus
2. H. pylori infection
3. Adenomatous polyp
4. Gastric ulcer
5. Duodenal ulcer

PREFERRED RESPONSE ▶
TAG
(M1.GI.29) A 34-year-old Nigerian born female presents with burning in her epigastric region. Ultimately, esophagoduodenoscopy (EGD) demonstrates an ulcer in the proximal duodenum. Which of the following treatments would best address the cause of her ulcer? Topic Review Topic

1. Antibiotics
2. Cessation of NSAID use
3. Surgical resection
4. Cimetidine
5. Omeprazole

PREFERRED RESPONSE ▶
TAG
(M1.GI.76) A 34-year-old Caucasian male presents with symptoms consistent with peptic ulcer disease. The physician suspects H. pylori infection and decides to perform a biopsy. By looking at Figure A, which site corresponds to the most likely location of the bacterium? Topic Review Topic
FIGURES: A          

1. A
2. B
3. C
4. D
5. E

PREFERRED RESPONSE ▶
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