History

• Abdominal pain

1. Localization – epigastric
2. Relation to food
3. Episodic

• Vomiting – persistent daily vomiting – GOO
• Anorexia, nausea, early satiety after meal
• F/O anemia- fatigue,  weakness, pallor
• Bleeding manifestations – bleeding PUD

1. black terry stool
2. Bloody stool
3. Blood vomiting

• Drugs- NSAIDs and aspirin 
• Smoking

 

Management 

Aim:

1. Relieve symptoms 
2. Induce healing
3. Prevent recurrence 

 

H.pylori eradication : 

• CAM+PPI → CAP for 10-14 days

 

NSAIDs

• Should be stopped 
• If long term NSAIDs needed, co-prescribed with PPI
• For low dose aspirin, PPI not needed

 

General measures 

• Cigarette smoking, aspirin, NSAIDs- should be stopped
• Alcohol- moderation

 

Maintenance treatment 

• After successful HP eradication – continuous maintenance treatment not needed
• Fir minority- lowest effective dose of PPI should be used

 

Surgical treatment : Indication

• Emergency 

Perforation,  hemorrhage 

• Elective

GOO, persistent ulcer despite adequate medical therapy 

 

Complications of gastric resection or vagotomy

1. Dumping

• Early- within 30 minutes after meal→ diarrhea, hypotension 

         → Tx: avoid large meal with high CHO content

• Late: 1-3 hours after meal → reactive hypoglycemia – nause, tremor, sweating 

      → Tx: eating more food

1. Chemical (bile reflux) gastropathy : Tx: UDCA, Roux en Y loop
2. Diarrhoea and maldigestion: Tx: small, dry meal with low refined CHO;  anti-diarrheal
3. Weight loss
4. Anaemia- IDA
5. Metabolic bone disease- Ca & vit -D → osteoporosis,  osteomalacia
6. Gastric cancer

 

Complications of PUD

1. Perforation
2. GOO
3. Bleeding 

 

Perforation 

• DU>GU, anterior wall
• Clinical features

1. Sudden, severe epigastric pain spreading to be generalised 
2. Shoulder tip pain- diaphragm irritation
3. Shallow respiration- limitation of diaphragmatic movement
4. Shock
5. Board like rigidity
6. Bowel sound – absent
7. Liver dullness- reduced
8. Disorientation, stupor

 

• Investigation 

1. CXR erect posture
2. Water soluble contrast study

• Management 

1. Resuscitations 
2. Surgery

• Mortality rate – 25%

 

Gastric outlet obstruction 

C/F

• Nausea, vomiting, abdominal distention 
• Wasting, dehydration
• Succussion splash- 4 hour or more after last meal or drink
• Visible gastric peristalsis 

Investigation

• Stomach has been emptied by wide bore NG tube
• Endoscopy of UGIT

 

Treatment 

• Correction of dehydration- in severe case, at least 4L of isotonic saline and 80 mmol of potassium – in first 24 hours
• PPI:

1. Heal ulcer
2. Reduce pyloric edema
3. May overcome need for surgery

• Endoscopic Balloon dilatation of benign stenosis
• Surgery

1. Partial gastrectomy
2. Gastroenterostomy with/without vagotomy

• if vagotomy not done- long term PPI to prevent stomal ulceration 

 

SAQ. A 30 year old smoker male came with recurrent localized upper abdominal pain that aggravate with empty stomach. His repeated USG of abdomen and a CT abdomen came normal

 

1. What are the methods you will do to diagnose this case as a H. Pylori related PUD? 

 

Test	Advantages	Disadvantages
Non-invasive: SUF
Serology	Rapid office kits available Good for population studies	Lacks specificity; cannot differentiate current from past infection
C-Urea breath test	High sensitivity and specificity	Requires expensive mass spectrometer
Fecal antigen test	Cheap, specific (>95%)	Acceptability
Invasive (antral biopsy with): RHC
Rapid urease test	Cheap, quick, specific > 95%	Sensitivity 85%
Histology	Specificity	False negatives  Takes several days to process
Microbiological Culture	‘Gold standard’  Defines antibiotic sensitivity	Slow and laborious Lacks sensitivity

 

1. Write down 2 extra gastric disorders where H. Pylori test is indicated?

Extra gastric disorders:

• Idiopathic thrombocytopenic purpura
• Unexplained iron deficiency anemia
• Unexplained Vitamin B12 deficiency

 

1. Write down 4 side effects of H. Pylori eradication therapy?

• Diarrhea: 30%-50% of patients; usually mild, but Clostridium difficile associated diarrhea can occur
• Flushing, and vomiting when taken with alcohol (metronidazole)
• Nausea, vomiting
• Abdominal cramps
• Headache
• Rash