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home - Stomach - Peptic Ulcer Disease - Peptic Ulcer Disease Bleed Treatment Written by Dr Sebastian Zeki
Knowledge

Knows the range of organic and non-organic causes of dyspepsia. Be
aware of current BSG and NICE guidelines for selecting patients for
investigation. Know the significance of alarm symptoms
Understands the relevance of Helicobacter pylori infection and how it
can be detected and treated.
Recognise the adverse effect of nonsteroidal anti-inflammatory drugs
Understands the physiology of gastric acid secretion, mucosal
protection and gastroduodenal motility and know how drugs can
modify these
Knows the complications of ulcer disease, the principles of surgery
that may be required and be aware of post-operative sequelae

Skills
Makes a thorough clinical assessment, perform appropriate
investigations and be familiar with how medical treatments are used.
Show awareness of how to recognise and manage complications

Behaviours
Can explain the steps taken towards making a diagnosis and
planning treatment clearly and comprehensibly

Also....

Knowledge
Knows the causes of upper gastrointestinal bleeding and its
presentation
Understands the circulatory disturbance associated with blood loss
and the pathophysiology underlying the clinical manifestations of
hypovolaemic shock
Knows the principles of assessing hypovolaemia and of restoring the
circulation. Be able to identify and correct coagulopathy
Knows the principles of using the various risk stratification tools SCE 1
Knows how endoscopic techniques are used to control bleeding CbD, DOPS, SCE 1
Understands how oesophageal and gastric varices develop and the
endoscopic and pharmacological methods that are used to control
blood loss

Skills
Can make an accurate clinical assessment, and stratify the risk. Know
the principles of fluid resuscitation and arrange endoscopy
Is aware of methods to secure haemostasis, recognise signs of rebleeding and liaise with other disciplines (such as interventional
radiology or surgery

Behaviours
Assesses and treats patients who have bleeding with appropriate
degree of urgency.

Also...
Knowledge


Understands why part or all of the patient’s stomach is removed and
the altered post-surgical anatomy

Understands the problems of a gastro-enterostomy and a Roux-en-y
anastomosis

Has awareness of dumping syndromes
Knows the various surgical operations performed for obesity (bariatric
surgery) and their complications

Skills
Can give nutritional advice and choose the appropriate method by
which an enteral feeding tube is inserted into the small bowel

Can initiate the use of pancreatic enzyme therapy
Has ability to recognise and treat early and late dumping syndrome
Behaviours
Able to help the patient carers friends and family understand how
the patient can be encouraged to gain weight

Works closely with dieticians and surgical colleagues

Peptic Ulcer Disease Bleed Treatment

Diagnosis: Need four jumbo pieces from ulcer margin Treatment 8-12 weeks then reassess (more likely if corpositis) Dont need further treatment after HP eradication if symptom free Multiple ulcers — Multiple simultaneous ulcers occur in 2 to 20 of patients with peptic ulcerNSAID use and gastrinoma should also be considered when multiple ulcers are encountered. Place: Epigastrium in 2/3rds with sometimes radiation to backDisappearance of symptoms does not guarantee ulcer healing Giant ulcers — (>2cm in diameter)Usually located on the posterior wall.Frequently complicated by bleeding and posterior penetration and, depending on location, by pyloric obstruction.The risk of microscopic malignancy in the macroscopi-cally benign giant ulcer is significantly higher (13 versus 3 %).The presence of a visible vessel in the ulcer crater may predict need for operation.Associated with:Older peopleMethamphetamine or cocaine useNSAIDsH. pylori is certainly an important factor in some giant ulcers Postbulbar ulcers — 10% of PUDUlcers beyond the second portion of the duodenum and into the proximal jejunum are characteristic of a gastrinoma and possibly other hyperse-cretory states.Higher rate of complications with post-bulbar ulcers. The differential diagnosis includes diverticulae, adhesive bands, annular pancreas, and neoplasia of the pancreas and duodenum. Ulcer Differentials:Cancers.Gastric lymphoma.Leiomyosarcoma.Primary gastric.Metastatic Malignant melanoma.Metastatic renal cell carcinoma.Duodenal neoplasia —very uncommon, but can occasionally present with GI bleeding or as an apparently benign ulcer.Infiltrative or granulomatous diseases —.Sarcoidosis (stomach most common GI source- always with pulmonary).Eosinophilic granuloma.Wegener's granulomatosis.Hypertrophic gastritis (including Menetrier's disease).Crohn's disease.Infections —.TB- often submucosal granulomata so may not pick up on biopsy.Mycobacterium avium intracellu-lare.Strongyloidiasis.Giardiasis. Endoscopic Features suggestive of malignant ulcer Factors decreasing the risk of gastric malignancy on endoscopy:NSAID use.Age <than 50.Absence of H. pylori.Presence of a simultaneous DU.The longer the ulcer history, the lower the risk a GU is cancer. Factors increasing the risk of gastric malignancy at endoscopy:-Age.-H. pylori.-Growing up in a region with high prevalence of gastric carcinoma.-Family history.-Ulcer size.-Presence of gastric atrophy, adenoma, dysplasia, and possibly intestinal metaplasia. A few cautions regarding diagnosis of GU malignancy at endoscopy-Becoming asymptomatic on treatment does not exclude malignancy -Biopsy healed ulcers as can still be dysplastic-Endoscopy less sensitive for GU when antisecretory agents taken Johnson classification of GU Based upon anatomic location and acid-secretory potential Features of Malignant GU Types of Gastric Ucers Other GU Types Can last weeks Character: Gnawing / burning / vague Can be silent especially if old or with NSAID use Steroids do not cause ulcers without NSAIDS At night when acid secretion maximal Type I gastric ulcer —Frequency: Most common formLocation: Along the lesser curvature at the junction of fundic and antral mucosaPathophysiology: Occur in the setting of acid hyposecretionTreatment: Distal gastrectomy with Billroth I or II reconstruction to remove ulcer and diseased antrum. HSV can be alternative (as per DU with gastrostomy)Outcome: Low recurrence rates (0 to 5 %) and excellent symptomatic relief are usually achieved Type II gastric ulcer —Frequency: They frequently occur in younger men and are associated with increased acid secretionLocation: Synchronous gastric and duodenal ulcerThey tend to be large, deep ulcers, with poorly defined marginsTreatment: Similar to duodenal ulcer, with vagotomy and antrectomy the preferred approach Type III gastric ulcer — Location: Type III ulcers are prepyloric, although no precise anatomic definition exists- 20% of antral ulcers are malignant Juxtapyloric ulcers, which occur at or within 2 cm of the pylorus, often present with complications. if extends into duodenum consider lymphoma- Pathophysiology: Increased acid secretion aggression Treatment: Approached in a manner similar to duodenal ulcer and type II gastric ulcer with vagotomy and antrectomy Type IV gastric ulcer —Location: Type IV gastric ulcer is distinguished by its anatomic location high along the lesser curvature, close to the gastroesophageal junctionAntral mucosa may extend to within 1 to 2 cm of the gastroesophageal junction; thus, type IV ulcers may simply represent a subset of type I gastric ulcerPathophysiology: Gastric hyposecretion and present early with dysphagia and refluxTreatment: Options: If the integrity of the distal esophagus can be assured, subtotal gastric resection (including the ulcer bed) is considered optimal Alternatives include a distal gastrectomy which is extended along the lesser curvature to include the ulcer, the Pauchet procedure Kelly-Madlener procedure in which distal gastrectomy is performed but the ulcer is left in place to avoid GOJ compromise 1 2 3 4 Margins are Overhanging, IrregularThickened Folds surrounding the ulcer crater are:NodularClubbedFused Protrudes into the lumen Differences with GU’s More common in the elderly 3-5 hours after eating 70% HP +ve Endoscopically: Greater curve/fundus/antrum more likely malignant Differences with DU’s: More common in younger men 95% HP +ve (but less in USA) Associated with blood gp O Family history in 30% DU relieved with food in 50% Epigastric pain before meals Endoscopically: HP ulcers occur in cap. NSAID ulcers in 2nd part Duodenal ulcers- Treatment: If doubt about DU for repeat OGD and fasting gastrin. 4-8 wk PPI then discharge. Dont need further treatment after HP eradication if symptom free, but most give 4-6 weeks tx. More likely if antritis. Do need follow-up if complicated DU. Written by Dr Sebastian Zeki

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