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home - Stomach - Peptic Ulcer Disease - Peptic Ulcer Disease Natural History 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 Natural History

Patients needing long-term maintenance:Those who have failed H. pylori eradication/ H. pylori -ve ulcers.Patients with a history of complications.Frequent recurrences.Patients with refractory, giant, or severely fibrosed ulcers Natural History of DU:There is a 75 % recurrence rate at 1yr (not always symptomatic).Relapse is the rule in the absence of successful anti-H. pylori therapy. Initial therapy of non-H. pylori ulcers Consider alternative aetiologies.H. pylori -ve duodenal ulcers should have another test to exclude H. pylori.Gastric ulcers have a 20 % chance of being a false-negative so patients should have a repeat test.Multiple biopsies of the ulcer margin are indicated to exclude malignancy in patients with GU.At least 3 biopsies of the antrum are also justified for urease testing for H. pylori, and, if negative, histology.Complicated ulcers need two tests (biopsy and CLO). Healing rates for antisecretory therapy H2 antags any dose show a healing rate of 75% for DU at 4 weeks, and 90% after 8 weeks of therapy with any dosing regime.PPI any dose gives 90% healing at 4 weeks.Antacids, misoprostol and sucralfate are better than placebo but not recommended.Prepyloric ulcers appear to heal more slowly and may be more likely to recur.Giant ulcers need 12 weeks of therapy. Follow-up after initial therapy for peptic ulcer —Duodenal ulcers, if uncomplicated, need no further endoscopy.Gastric ulcers have a cancer risk of 2%.GU need >4 jumbo margin biopsies from the ulcer margin or 7 regular biopsies + 1 from base, if the ulcer is not too deep.Rescope GU 6-8 weeks after ulcer developed. Natural History And Treatment of Peptic Ulcer Disease HEALING Healing Time PPI H2 receptor antag Factors influencing peptic ulcer course Smoking — Smokers were more likely to develop ulcers, and the ulcers were more difficult to treat and were associated with a higher rate of recurrence.Not a relapse risk once H. pylori has been eradicated. Smoking is a risk factor for PUD before, but not after H. pylori eradication NSAIDs— Characteristics of the patient — -Elderly have reduced healing rates and increased complication rate-Simultaneous DU and GU may have delayed healing and a more complicated course.-Stress ulcers respond poorly to medical and surgical therapy. Characteristics of the ulcer — Giant ulcers are very slow to heal and require sustained treatment simply because of their size (all ulcers heal at 3mm/week)Dense scarring leads to impaired healing and increased relapse rates. Stenosis or deformity of the duodenal bulb predicts impaired healing and enhanced relapse rates. Recurrence Time(yrs) Placebo- recurrenc of 67%.Highest recurrence in first year 20 mg dose taken three days per week reduced recurrences to 23 % at six months 5 If stop after a year, recurrence rates are the same as placebo Antisecretory therapy appears to remain effective for more than five years Greatest recurrence risk is within first year Antisecretory therapy after H. pylori eradication No PPI is needed post- eradication for uncomplicated, small (<1 cm) DU or GU.Complicated DU/ Hi risk need OGD 4-12 wks after completion of H. pylori therapy-stop therapy if improved. Management of H. pylori +ve DU.Acid suppression can be discontinued in patients with uncomplicated DU after 4 weeks.Maintenance acid suppression (even after successful H. pylori eradication)should carry on indefinitely in uncomplicated DU’s.Eradication should be confirmed.If the patient needs ongoing NSAID, then maintain on PPI for its duration. Other tips:The absence of antral gastritis is evidence for HP cure.If low risk ulcer, then switch from PPI to full dose H2RA for 2 weeks pre-OGD; this is an adequate time to reduce false negative results in the majority of patients If H. pylori testing was not done or if tests were negative on PPI, then follow-up testing is indicated at a time when the PPI can be stopped (or switched to H2 receptor antagonists) for 2 weeks. Written by Dr Sebastian Zeki

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