What is dyspepsia? Peptic Ulcer Diseases - Site, Pathophysiology, Clinical feature, Investigation, Treatment

1. Izatty Lim
0308188
Batch 4

2. 
 defined as having one or more symptoms of
epigastric pain, burning, postprandial fullness, or
early satiety.
 Bloating
 Nausea
 Loss of appetite
Dyspepsia

3. 
PUD

4. 
 Type I
 typically located near the angularis incisura on the lesser
curvature, close to the border between the antrum and the
body of the stomach. Patients with type I gastric ulcers
usually have normal or decreased gastric acid secretion.
 Type II
 a combination of stomach and duodenal ulcers and are
associated with normal or increased gastric acid secretion.
 Type III
 prepyloric and are associated with normal or increased
gastric acid secretion.
 Type IV
 occur near the gastroesophageal junction, and gastric acid
secretion is normal or below normal.
Types of Gastric Ulcer

5.  Etiology:
 H. pylori bacterium
 NSAID
Gastric Ulcer

6.  H. pylori
 70% of gastric ulcer patients are infected with H. pylori.
Majority of colonised people remain healthy and
asymptomatic.
 uses adhesin molecules (BabA) to bind to Lewis b antigen on
epeithelial cells.
 induces an intense inflammatory and immune response
 IL-1, IL-6, tumor necrosis factor, IL-8
 Production of ammonia by the enzyme urease
 Toxic to epithelial cell
 Increase gastrin release from G cells
 Negative feedback loop for gastrin release is halted
 stimulates increased acid production by parietal cells.
Pathophysiology

7. 
 NSAID
 Direct chemical irritation & COX enzyme inhibition,
which prevent prostaglandin synthesis
 increases secretion of hydrochloric acid and reduces
bicarbonate and mucin production
 Damage gastric and duodenal mucosal barrier
 increased risk of upper gastric ulcer, bleeding
&perforation.
Pathophysiology

8. 
 Smoking
 Increased risk of gastric ulcer and duodenal ulcer to a
lesser extent.
 more likely to causing complication and less likely to
heal if the patient continues to smoke.
Pathophysiology

9. 
 recurrent abdominal pain
 localisation to the epigastrium
 Relation to food
 Episodic occurrance
 Occasional vomiting
 Anorexia & nausea
 Completely ‘silent’
 presented with anaemia for the first time
 Recurrent acute bleeding without ulcer pain
 Gnawing or burning sensation
 occurs shortly after meals with gastric ulcer and 2-3 hours afterward
with duodenal ulcer.
 Diagnostic value of individual symptoms for PUD is poor.
Clinical Features

10. 
 Upper GI endoscopy
 Rapid urease tests
 Fecal antigen testing
 detecting the presence of H pylori antigens in stools
 Urea breath test
 testing for the enzymatic activity of bacterial urease.
 Antibodies (IgG)
 X- ray
 detect free abdominal air when perforation is suspected.
 upper GI contrast study
 extravasation of contrast indicates gastric perforation
Investigation

11. 
 H. pylori eradication
 proton pump inhibitor (PPI)–based triple therapy.
 PPI, amoxicillin, and clarithromycin for 7-14 days.
 Amoxicillin should be replaced with metronidazole in penicillin-
allergic patients only  high rate of metronidazole resistance
 NSAID
 American College of Gastroenterology (ACG ) guideline: test
for H pylori done in patients who started long-term NSAID
therapy
 NSAIDs should be immediately discontinued in patients with
positive H pylori test results if clinically feasible
 Patient with known history of ulcer and in whom NSAID use is
unavoidable, the lowest possible dose and duration of the
NSAID and co-therapy with a PPI or misoprostol are
recommended.
Treatment

12. 
 Surgical
 Rarely required
 Choice for a chronic non-healing gastric ulcer
 partial gastrectomy to exclude an underlying cancer.
Treatment

13. 
 Duodenal ulcer and gastric ulcer both belong to the
family of peptic ulcer disease.
 H. pylori infection is the major cause of duodenal
ulcer followed by NSAID
 They share almost the same clinical features.
Duodenal Ulcer

14. 
 Gastric Ulcer
 Symptoms do not
follow a consistent
pattern
 Eating sometimes
exacerbates rather
than relieves pain
Gastric Ulcer vs Duodenal Ulcer
 Duodenal Ulcer
 Tend to cause more
consistent pain.
 Pain can awaken the
patient at night.
 Pain is relieved by
food, but recurs 2 to
3 hours after a meal

15. 
Complication
Stricture
•Gastric outlet
obstruction
•Abdominal distension
•Nausea, vomiting
•Diagnosis by visible
gastric peristalsis
Perforation
•Sudden severe pain then
become generalized
•Irritation of diaphragm
leading to shoulder tip
pain
Peritonitis
•Paralytic ileus
•Absent bowel sound
•Abdominal guarding

16. 
 Harmon RC, Peura DA. Evaluation and Management of
Dyspepsia [Internet]. Medscape. [cited 2015 May 24]. Available
from: http://www.medscape.com/viewarticle/721062_1
 Robbins basic Pathology. 9th Ed.
 BS Anand. Peptic Ulcer Disease Treatment & Management
[Internet]. [cited 2015 May 24]. Available from:
http://emedicine.medscape.com/article/181753-
treatment#aw2aab6b6b1aa
 Davidson’s Principle & Practice of Medicine. 22nd Ed.
References