QuestionSBA
QuestionChoice
Zollinger-Ellison syndrome presents with recurrent ulcers in the stomach and duodenum secondary to excessive gastrin levels released from gastrinomas, which are malignant. Gastrin stimulates mucosal growth of the stomach and the release of acid from gastric parietal cells. These patients also present with diarrhoea due to excessive gastric acid leading to inactivation of lipase and subsequent fat malabsorption. Endoscopy would reveal multiple ulcers, as well as thickened gastric folds. This condition is commonly associated with multiple endocrine neoplasia 1 (MEN1.) Treatment is with high dose PPI or somatostatin analogues.
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Zollinger-Ellison syndrome
QuestionChoice
Oesophageal cancer typically presents with progressive dysphagia, initially for solids and eventually for liquids, as well as hoarseness of the voice if there is compression of the recurrent laryngeal nerve which runs close to the oesophagus in the thorax. Risk factors include smoking, acid reflux (due to Barrett's oesophagus), and high levels of alcohol intake. Helicobacter pylori causes achlorhydria chronically, and as such is actually protective against oesophageal adenocarcinoma. Weight loss and anorexia may also occur. This patient's endoscopy reveals no oesphageal lesion, with the only finding in the stomach, and reports no dysphagia. Therefore, oesophageal malignancy is unlikely.
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Oesophageal cancer
QuestionChoice
Crohn's disease is an inflammatory bowel disorder, which can present with abdominal pain and weight loss. Additional clinical features usually include diarrhoea, which is absent in this case. Inflammation can be present throughout the entire GI tract,  from mouth to anus, and additional clinical features, such as mouth ulcers, may be present. The history of abdominal pain worse on eating, relieved by antacids, and the appearances on endoscopy, are not consistent with a diagnosis of Crohn's disease.
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Crohn's disease
QuestionChoice
This patient's endoscopy findings are in keeping with a peptic ulcer. His symptoms of epigastric pain, worsened on eating, typically indicate a gastric ulcer (with pain from duodenal ulcers relieved by eating.) This patient has rheumatoid arthritis, and it is possible he may use NSAIDs frequently; this, alongside his smoking history, places him at higher risk of peptic ulcer disease.  Another key risk factor is Helicobacter pylori infection, which this patient will be tested for during endoscopy. It is important to note that this patient was referred for endoscopy appropriately under the 2-week-wait pathway as he fit the criteria for urgent investigation due to his age over 55, weight loss, and abdominal pain, in line with NICE guidance.
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Peptic ulcer disease
QuestionChoice
Gastric cancer may also present with epigastric pain, weight loss,  and anorexia. Patients may also have iron deficiency anaemia. Risk factors for gastric cancer are similar to peptic ulcer disease, and include smoking as well as Helicobacter pylori infection. The endoscopic appearances here are in keeping with an ulcer, however, as opposed to gastric cancer, and the clinical feature of pain worsening on eating should also raise suspicion of an ulcer.
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Gastric adenocarcinoma
QuestionComment
man said unintenional weight loss and smoking history. WHAT YOU PLAYING AT QUESMED?
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QuestionComment
I think it's because unintentional weight loss and smoking history can be suggestive of cancer, and that's why he'd qualify for an endoscopy. But the endoscopy findings are not consistent with gastric carcinoma 
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Embolism Womb
User
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Serpiginous Yeast
QuestionComment
and the weight loss could have been eluded to the fact that he may not be eating as much
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BeethovenVirus-ed
Concept
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# Summary

Peptic ulcer disease, encompassing both duodenal and gastric ulcers, is a condition where the stomach lining's self-protection mechanisms fail, often due to the presence of external factors like H. Pylori. Key signs and symptoms include pain, nausea, vomiting and loss of appetite. The primary investigation tool is endoscopy, which allows for a direct visual inspection of the ulcers. Management strategies include both pharmaceutical interventions, such as PPI treatment, and lifestyle changes, like cessation of smoking and dietary adjustments.

# Definition

Peptic ulcer disease refers to painful sores or ulcers in the lining of the stomach or the first part of the small intestine, known as the duodenum. The frequency of duodenal ulcers is four times higher than that of gastric ulcers. It is an endoscopic diagnosis (NB: dyspepsia is a clinical diagnosis). Peptic ulcer disease can be uncomplicated, or complicated (perforation, bleeding).

# Epidemiology

Peptic ulcer disease is a common condition, with the prevalence of duodenal ulcers being four times that of gastric ulcers. It's noteworthy that approximately 90% of duodenal ulcers are caused by H. Pylori infection.

# Aetiology

The primary cause of duodenal ulcers is the infection by H. Pylori. Other factors contributing to the development of these ulcers include:

- NSAIDs
- Chronic use of steroids
- SSRIs
- Increased secretion of gastric acid
- Smoking
- Blood group O
- Accelerated gastric emptying  

For gastric ulcers, the risk factors include:

- NSAIDs
- H. Pylori infection
- Smoking
- Delayed gastric emptying
- Severe stress

# Signs and Symptoms

Patients with peptic ulcer disease may present with:

- Abdominal pain
- Nausea
- Vomiting
- Loss of appetite
- Unexplained weight loss
- Patients with complicated peptic ulcer disease may present with coffee ground vomiting (bleeding), and can be haemodynamically unstable due to perforation

Duodenal ulcers typically present with epigastric pain typically relieved on eating (closure of pyloric sphincter, less acid irritating ulcerated surface). Symptoms of gastric ulcers on the other hand are often worsened by eating - stomach increases acid production in response to food and irritates ulcerated surface.

# Differential Diagnosis

The symptoms of peptic ulcer disease can mimic those of other conditions, including:

- Gastritis: inflammation of the stomach lining, presenting with nausea, vomiting, and abdominal discomfort.
- Gastro-oesophageal reflux disease (GORD): chronic acid reflux, characterized by heartburn, regurgitation, and swallowing difficulties.
- Stomach cancer: may cause similar symptoms, but often accompanied by significant weight loss, loss of appetite, and anemia.

# Investigations

- Patients >55 with weight loss and dyspepsia should be referred for an urgent OGD (within 2 weeks) to investigate for oesophageal and gastric cancer
- Patients should be investigated for H.pylori infection with C-13 urea breath test (ensure the person has not taken a PPI in the past 2 weeks, or antibiotics in the past 4 weeks)
- Investigation tools for peptic ulcer disease primarily include endoscopy, which allows a direct visual inspection of the ulcers. Biopsies may be taken to rule out malignancy.

# Management

Management of H. Pylori-negative peptic ulcer disease involves a 4-8 week course of full-dose PPI treatment in conjunction with lifestyle advice, such as:

- Smoking cessation
- Reducing alcohol intake
- Regular, small meals and avoiding eating 4 hours before bedtime
- Avoidance of acidic, fatty or spicy foods, and coffee
- Weight loss if overweight 
- Stress management
- Avoidance of NSAIDs, steroids, bisphosphonates, potassium supplements, SSRIs, and crack cocaine
- Over-the-counter antacids


- If the patient is H.pylori positive with a proven gastric/duodenal ulcer which is:
	- Associated with NSAID use: 8 week PPI therapy followed by first-line eradication therapy - PPI (omeprazole/lansoperazole) + amoxicillin + clarithromycin/metronidazole for 7 days
		- If penicillin allergic, offer: PPI + clarithromycin + metronidazole for 7 days 
	- Not associated with NSAID use: eradication therapy with PPI (omeprazole/lansoperazole) + amoxicillin + clarithromycin/metronidazole for 7 days
	- If the person is allergic to pencillin and has had previous exposure to clarithromycin, offer a 7-day quadruple therapy regimen of:
PPI + metronidazole + tetracycline hydrochloride + bismuth subsalicylate

- For patients with gastric ulcers, a repeat endoscopy 6-8 weeks following the start of PPI treatment is recommended to ensure ulcer healing and rule out malignancy, as well as H.pylori re-testing (C-13 urea breath test first-line, stool antigen test second line) if appropriate.
- Complicated peptic ulcer disease requires urgent surgical intervention with OGD for underunning of ulcers and haemostasis
	- Perforated peptic ulcers present initially with localised epigastric pain which later becomes generalised and peritonitic. These patients require an AXR and erect CXR to look for pneumoperitoneum. 

# NICE Guidelines

[Click here to see more information NICE CKS on peptic ulcer disease](https://cks.nice.org.uk/topics/dyspepsia-proven-peptic-ulcer/management/management-proven-peptic-ulcer/)
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Peptic ulcer disease
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Gastroenterology
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Peptic ulcer disease
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Approach to Epigastric pain
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Peptic ulcer disease can present with epigastric pain exacerbated by eating, often associated with NSAID use and smoking history.
A 57-year-old male presents to the GP with a 7-month history of epigastric pain which gets worse after eating. Over the same time period, he has lost his appetite and 1.5kg unintentionally. He has a past medical history of rheumatoid arthritis and a smoking history of 31 pack years. He admits that he often uses over-the-counter antacids, which help occasionally. He is referred for a two-week wait upper gastrointestinal endoscopy, which reveals granulation tissue with a necrotic layer.

Which of the following is the most likely diagnosis?
a