Peptic Ulcer Disease - NEET PG Medicine

When acid in the digestive tract eats away at the inner surface of the stomach or the small intestine, it leads to peptic ulcers. When this happens, it can create painful open sores that might bleed. 

Usually the most common cause of ulcers is infection of the stomach by bacteria called Helicobacter pylori and most people who suffer from peptic ulcers have these bacteria living in their digestive tract.  

Peptic ulcer disease is one of the most important and recurring topics in Medicine. Read this blog post thoroughly and boost your Medicine preparation for NEET PG. 

Type B Gastritis

Warthin Starry Stain

• In the following picture black dots represent presence of Helicobacter Pylori

Helicobacter pylori 

• Leading cause of PUD: Type B gastritis
• Gram negative coccobacilli
• Non-Sporing: eradication possible
• Route of spread: Feco-oral route   
• Extra Cellular Bacteria / Microaerophilic
• Mechanism of action:

Urea

urease

Ammonia (Alkaline) ↓ Irritation of G cells& parietal cell ⊕ ↓ Excessive acid production (Hyper chlorhydria) ↓ Ulcer Duodenal ulcer>Gastric ulcer

Work Up       

• Screening test → Breath urea test (Non-invasive)
• Urease test (Invasive) (CLO TEST- commercial name) → stomach scraping during endoscopy
• Biopsy: Warthin starry stain

Treatment  

Antibiotics            

• Triple Therapy x 2 weeks
  • Pantoprazole (PPI)
  • Clarithromycin
  • Amoxicillin/clavulanic acid
• Quadruple therapy
  • Bismuth
  • Tetracycline
  • Metronidazole 
  • Pantoprazole
• Erythromycin Not used for treatment
• Bismuth acts by reducing acid-mucosa contact time

Type A Gastritis

Autoimmune disorder, premalignant condition

• Anti-parietal cell antibodies
• Achlorhydria → gastric ulcer
• Intrinsic factor deficiency, B12 deficiency: Pernicious anemia
• Hypergastrinemia, Achlorhydria

Gastric ulcer		Duodenal ulcer
Blood group	A	O
Site	Type 1: lesser curvature (MC site) near incisura Angularis	D1: Duodenal Cap First part of duodenum
Pain	Epigastric pain (Immediately after food Intake) weight loss	Epigastric pain "hunger pain" Snacking by patient leads to weight gain

Important Information H. Pylori is an Extracellular bacterium while Tropheryma whippelei leading to Whipple’s disease is intracellular bacteria found inside macrophages of intestine.

Also Read: EPILEPSY AND Electroencephalography (EEG) : NEET PG Medicine

Workup

• Investigation of choice: Upper GI endoscopy (UGIE) + Biopsy
• Urease test

Treatment

• PPI x 6 weeks

Important information Refractory PUD may be due to Zollinger-Ellison Syndrome

Complications of Gastric and Duodenal ulcer

Gastric ulcer

• Bleeding: Left gastric Artery
• Management:
  • When hemodynamically stable
  • Upper GI Endoscopy +Cautery 
• Perforation: Lesser sac peritonitis
• Penetration
  • Slow, posteriorly present
  • Necrotizing pancreatitis
• Gastric outlet obstruction (GOO): Tea pot stomach

In duodenal ulcer

• Perforation (Most common): Anterior > posterior 
• Most common cause of peritonitis
• Moustache sign: Gas under diaphragm
• Bleeding: Posterior > Anterior Source - Gastroduodenal artery
• Management: 
  • Adrenaline at base of ulcer
  • Cautery, ligation, exploratory laparotomy

Gas under diaphragm: moustache sign: Pneumoperitoneum	Pneumomediastinum; continuous diaphragm sign (air around the heart)	Subcutaneous emphysema		Coffee bean appearance, Bird beak appearance: Sigmoid volvulus	Bird beak appearance in barium enema: Sigmoid volvulus

Sigmoid Volvulus 

• 60-year-old: Left iliac fossa pain, Obstipation (Can't even pass flatus)
• X- Ray abdomen: Coffee bean sign
• Barium enema: Bird BEAK appearance

Treatment

• Intravenous Fluids
• Flatus tube
• Colonoscopic detorsion

A 60 years old, non-vegetarian with chronic constipation having LIF pain + Hematochezia Diagnosis: Diverticulitis Investigation:  CT abdomen

Pre-Malignant Conditions of Gut                              

Oral cavity

Gutka/ Betel nut

• Oral submucosal fibrosis
• Leukoplakia: More common
• Erythroplakia: More malignant
• Syphilitic glossitis

Esophagus

• Tylosis palmaris: Hyperkeratosis in palms and soles 
• Achalasia cardia
• Barrett’s esophagus
• Plummer Vinson syndrome: Esophageal web +IDA (Iron deficiency anemia) + Koilonychia (spoon shape defect on nails)

Stomach

• Type A Gastritis/Gastric ulcer
• Menetrier’s disease
  • Proliferation of foveolar cells ⊕ & ↓parietal cells → Achlorhydria → Gastric ulcer
• Cerebriform appearance of stomach mucosa

Treatment: Cetuximab

Premalignant Conditions

Small Intestine

• Crohn's disease
• Cronkhite Canada Syndrome: Polyps in duodenum
  • Sporadic hamartomatous polyp ⊕

Large Intestine

• Inflammatory bowel disease
• Familial adenomatous polyposis (FAP)
  • APC gene
  • Chromosome 5 defect
  • >100 polyps / colon
  • Primary colectomy (Prophylactic)

Peutz Jehger Syndrome      

• Autosomal dominant
• STK 11 / LMB 1 gene, AD
• Chromosome 19 
• Hamartomatous polyps in jejunum that lead to bleeding, obstruction & intussusception

Mucosal melanosis

Arborizing pattern

• Most common site: Jejunum
• Increased incidence of Ca stomach / ovary / cervix/ Hepatobiliary cancer
• Polyps themselves are not premalignant but a definitive association with both intestinal, hepatobiliary, and extra intestinal malignancy.

And that is everything you need to know about Peptic ulcer Disease for your Medicine preparation. For more interesting and informative blog posts like this, download the PrepLadder App and keep following our blog.