clinical medicine students notes

1. PEPTIC ULCER DISEASE
Michael E.

2. o Gastric Anatomy
o Gastric Physiology
o PUD
 Introduction/ definition
 Etiology
 Epidemiology
 pathophysiology
 Clinical presentation
 Differential diagnosis
 Investigation
 Treatment
 Complications
CONTENTS

3. Anatomy of Stomach
A muscular sac situated
between the esophagus
and small intestine.
Openings
o Gastroesophageal : To
esophagus
o Pyloric: To duodenum

4. Anatomy of Stomach
Sphincters
o Cardiac/LES/ gastro esophageal
sphincter
o Pyloric sphincter

5. Anatomy of Stomach
Anatomical Parts of
the stomach
oCardia
oFundus
oBody
oAntrum
oPylorus

6. Anatomy of Stomach
Nerve supply-
o Vagus
Blood Supply
o Left and Right Gastric
Arteries
o Splenic Artery
Venous Drainage
o Left and Right Gastric
Vein
o Splenic Vein

7. Gastric Physiology
Function of Stomach
o Temporary storage
o Digestion
o Absorption
o Gastric secretion
Two types of glands
o Gastric/ Oxyntic glands
o Pyloric glands

8. Gastric Physiology
Gastric gland
Comprises of the
following secreting
cells
o Mucous neck cells
o Peptic/Chief cells
o Parietal Cells

9. Gastric Physiology
Pyloric Glands
Comprises of:
o G cells- Gastrin
Hormone
o Mucous secreting
cells

10. Mwajuma who is 32yrs of age complain abdominal pain for
two months now, it was of gradual onset, located at
epigastric region and radiates to the back. Over the past 4
days she vomited blood 2 times and had dark stool. On per
abdominal exam there was epigastric tenderness, other
systems were essentially normal.
a. What is your likely diagnosis
b. What are the possible causes of your diagnosis
c. What is the pathophysiology of your diagnosis
d. How will you investigate Mwajuma’s illness
e. Provide expertise management of Mwajuma’s illness
Warm up

11. PEPTIC ULCER DISEASE
An Ulcer is breaks in
mucosal surface of
stomach/ duodenum
PUD has two types
o Gastric ulcer
o Duodenal ulcer

12. Causes/ Risk Factors
H Pylori
NSAIDS
Stress HCL
Genetic O DUs A GUs

13. Causes/ Risk Factors
Smoking
Alcohol
Diet
Spicy food
Coffee

15. Epidemiology
Gastric Ulcer
Occur later in life, peak
incidence at sixth
decades
More than half occur in
males
Unlike DUs, Gus can
represent a malignancy
Duodenal Ulcer
Occur mostly in the first
part of the duodenum
Malignant DUs are
extremely rare

16. o Give differences between Gastric ulcers and Duodenal
Ulcers

17. Pathophysiology

18. Pathophysiology

19. Pathophysiology

20. Clinical Presentation

21. Clinical Presentation
Epigastric pain
Abdominal pain- burning
Nausea and Vomiting
Heart burn
Loss of appetite
Hematemesis
Black Stool
Indigestion
Weight loss
Fatigue

24. Differential diagnosis
Functional Dyspepsia
(NUA)
GERD
Gastritis
Chronic Pancreatitis
Gastroenteritis
Irritable bowel Syndrome

25. Diagnostic Evaluation

26. Investigation
Serum antibody for H
Pylori
Stool Antigen for H Pylori
Blood Culture &
Sensitivity
Urea breath test
Endoscopy
Barium Meal

27. Endoscopy
(Oesophagogastroduedenoscopy )

28. Endoscopy

29. Barium Meal

30. Treatment

31. 1. Drugs for reduction of acid secretion
Proton Pump ( H+,K+-ATPase) Inhibitors
o Omeprazole, Pantoprazole, Rabeprazole,
Lansoprazole, Dexlansoprazole,
H2 Receptor Blockers
o Ranitidine, Famotidine, Cimetidine ,Roxatidine
Anticholinergics
o Pirenzepine, Propantheline ,Oxyphenonium
Treatment

32. 2. Drugs to neutralize acid ( antacids)
Magnesium trisilicate, Mg Hydroxide
Aluminum hydroxide
Sodium bicarbonate
Treatment

33. 3. Mucosal Protective Agents
Sucralfate, Eg sucralfate 1g qd
Bismuth; eg bismuth subalicylate,
Ranitidine bismuth citrate
Prostaglandin Analogue Eg Misoprotol
Treatment

34. 4. Antimicrobial drugs for H Pylori Eradication
Amoxicillin
Clarithromycin
Metronidazole
Tinidazole
Tetracycline
Treatment

35. Regime for H Pylori Eradication
Two antibiotics
& PPI
Amoxicillin 2g bid
Metronidazole 500mg td
Omeprazole 20mg bid
For 2 weeks
Lansoprazole 30mg bid
Clarithromycin 500mg bid
Tinidazole 500mg bid
2weeks
Clarithromycin 500mg bid
Metronidazole 500mg bid
Omeprazole 20mg/
lansoprazole 30md bid
for 2 weeks

36. CLINICAL SETTING RECOMMENDATION
ACTIVE ULCER
o NSAID Discontinued H2 Blocker or PPI
o NSAID Continued PPI
PROPHYLATIC THERAPY Misoprostol
PPI
Recommendation for treatment of
NSAIDS related-PUD

37. complications

38. A patient presents to you with recurrent epigastric pain
that radiates to the back, more worse on later food
intake, H Pylori test is Negative and OGD shows
moderate breaks in gastric and duodenal mucosa,
which of the following is the correct treatment of this
patient?
a. Initiate two antibiotics and one PPI for 6 weeks
b. Initiate two antibiotics and one PPI for 2 weeks
c. Initiate PPI or H2 receptor blocker for 6 weeks
d. Initiate PPI or H1 receptor blocker for 4 weeks
e. Initiate PPI or H2 receptor blocker for 4 weeks
QUESTIONS

39. In the stomach lining, the parietal cells release…..and
the chief cells release….. Which both play a role in
peptic ulcer disease.
a. Pepsin, HCL
b. Pepsinogen, pepsin
c. Pepsinogen, gastric acid
d. HCL, Pepsinogen
QUESTIONS

40. You see a 47years old man in clinic with a 3 month history of
epigastric dull abdominal. He states that the pain is worse in
the mornings and relieved after meals. On direct questioning,
there is no history of weight loss and the patients has normal
bowel habits. On exam moderate discomfort on the
palpation at epigastric . What is the most likely diagnosis
a. Gastric ulcers
b. Gastro-esophageal ref lux disease
c. Duodenal ulcer
d. Gastric cancer
e. Gastritis
QUESTIONS

41. Mwajuma who is 32yrs of age complain abdominal pain
for two months now, it was of gradual onset, located at
epigastric region and radiates to the back. Over the
past 4 days she vomited blood 2 times and had dark
stool. On per abdominal exam there was epigastric
tenderness, other systems were essentially normal.
a. What is your likely diagnosis
b. What are the possible causes of your diagnosis
c. What is the pathophysiology of your diagnosis
d. How will you investigate Mwajuma’s illness
e. Provide expertise management of Mwajuma’s illness
QUESTIONS