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What is the most common type of peptic ulcer?
What is the most common type of peptic ulcer?
Peptic ulcer disease can occur at any age.
Peptic ulcer disease can occur at any age.
False
What role does Helicobacter pylori play in peptic ulcer disease?
What role does Helicobacter pylori play in peptic ulcer disease?
It contributes to ulcer formation by producing enzymes that reduce mucous gel efficacy and triggers an inflammatory response that damages gastric epithelial cells.
PUD is more common in individuals who smoke and use _____ long-term.
PUD is more common in individuals who smoke and use _____ long-term.
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Match the following age groups with the corresponding type of ulcer:
Match the following age groups with the corresponding type of ulcer:
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Which factor does NOT seem to contribute to the development of Peptic Ulcer Disease?
Which factor does NOT seem to contribute to the development of Peptic Ulcer Disease?
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Bicarbonate secretion by epithelial cells helps maintain the mucosal barrier of the stomach.
Bicarbonate secretion by epithelial cells helps maintain the mucosal barrier of the stomach.
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An ulcer develops when the mucosal barrier fails to protect the mucosa from _____ and _____ .
An ulcer develops when the mucosal barrier fails to protect the mucosa from _____ and _____ .
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Which type of NSAIDs may be less damaging to the gastric mucosa?
Which type of NSAIDs may be less damaging to the gastric mucosa?
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Gastric ulcers are associated with a decreased risk of gastric cancer.
Gastric ulcers are associated with a decreased risk of gastric cancer.
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What infection is often linked to the development of peptic ulcer disease (PUD)?
What infection is often linked to the development of peptic ulcer disease (PUD)?
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Cigarette smoking can double the risk of developing __________.
Cigarette smoking can double the risk of developing __________.
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Match the type of ulcer with its common characteristics:
Match the type of ulcer with its common characteristics:
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What is the effect of aspirin on the gastric epithelial cells?
What is the effect of aspirin on the gastric epithelial cells?
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Peptic ulcer disease can be chronic with periods of spontaneous remission.
Peptic ulcer disease can be chronic with periods of spontaneous remission.
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Name one recommendation for patients with a history of long-term NSAID use.
Name one recommendation for patients with a history of long-term NSAID use.
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The most ulcerogenic NSAID is __________.
The most ulcerogenic NSAID is __________.
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Match the risk factor with its description:
Match the risk factor with its description:
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What is the typical nature of the pain experienced in peptic ulcer disease (PUD)?
What is the typical nature of the pain experienced in peptic ulcer disease (PUD)?
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In older adults, peptic ulcer disease often presents with clear and localized discomfort.
In older adults, peptic ulcer disease often presents with clear and localized discomfort.
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What symptom may indicate a complication of peptic ulcer disease in older adults?
What symptom may indicate a complication of peptic ulcer disease in older adults?
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The classic pain–food–relief pattern in PUD typically means that pain is relieved by _____ .
The classic pain–food–relief pattern in PUD typically means that pain is relieved by _____ .
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Match the symptom with its associated complication of peptic ulcer disease:
Match the symptom with its associated complication of peptic ulcer disease:
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Which of the following is NOT a symptom of gastric outlet obstruction related to peptic ulcer disease?
Which of the following is NOT a symptom of gastric outlet obstruction related to peptic ulcer disease?
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Hematemesis refers to vomiting blood as a complication of peptic ulcer disease.
Hematemesis refers to vomiting blood as a complication of peptic ulcer disease.
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What is a potential sign of slow, insidious bleeding from a peptic ulcer?
What is a potential sign of slow, insidious bleeding from a peptic ulcer?
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What is the most lethal complication of Peptic Ulcer Disease (PUD)?
What is the most lethal complication of Peptic Ulcer Disease (PUD)?
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Older adults typically present classic symptoms of perforation in PUD.
Older adults typically present classic symptoms of perforation in PUD.
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What type of tumor is associated with Zollinger-Ellison syndrome?
What type of tumor is associated with Zollinger-Ellison syndrome?
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The loss of ___ and ___ in vomitus can result in fluid and electrolyte imbalance.
The loss of ___ and ___ in vomitus can result in fluid and electrolyte imbalance.
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Match each complication of PUD with its description:
Match each complication of PUD with its description:
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Which PUD treatment is aimed at eliminating H. pylori infection?
Which PUD treatment is aimed at eliminating H. pylori infection?
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Diarrhea and steatorrhea are commonly seen in Zollinger-Ellison syndrome due to impaired fat digestion.
Diarrhea and steatorrhea are commonly seen in Zollinger-Ellison syndrome due to impaired fat digestion.
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List two signs of shock that may be present in a perforation case.
List two signs of shock that may be present in a perforation case.
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Chemical peritonitis from ___ acid is the immediate response to ulcer perforation.
Chemical peritonitis from ___ acid is the immediate response to ulcer perforation.
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Match the following terms with their associated characteristics:
Match the following terms with their associated characteristics:
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What happens during the perforation of an ulcer?
What happens during the perforation of an ulcer?
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Classic symptoms of peptic ulcer perforation include vomiting and fever.
Classic symptoms of peptic ulcer perforation include vomiting and fever.
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Name one treatment approach for an obstructed peptic ulcer.
Name one treatment approach for an obstructed peptic ulcer.
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Gastric ulcers are often treated with - antagonists.
Gastric ulcers are often treated with - antagonists.
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Study Notes
Peptic Ulcer Disease (PUD)
- PUD is a chronic condition caused by a break in the mucus lining of the gastrointestinal (GI) tract where it contacts gastric juice.
- Affects approximately 1 to 2 per 1000 individuals annually.
- Ulcers can occur in any area of the GI tract exposed to acid-pepsin secretions, including the esophagus, stomach, and duodenum.
- Duodenal ulcers are most common, typically developing between ages 30 and 55, and more prevalent in men.
- Gastric ulcers, located in the stomach, are more frequent in older individuals between 55 and 70.
- Smoking and long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs) are associated with an increased risk of PUD.
- Alcohol and diet do not appear to cause PUD, and the role of stress is uncertain.
Pathophysiology
- The innermost layer of the stomach wall, the gastric mucosa, is protected by the mucosal barrier, a thin coating of mucous gel and bicarbonate.
- This barrier is maintained by bicarbonate secreted by epithelial cells, mucous gel production stimulated by prostaglandins, and adequate blood supply to the mucosa.
- Ulcer formation occurs when the mucosal barrier fails to protect the mucosa from damage by hydrochloric acid and pepsin, the gastric digestive juices.
Helicobacter pylori Infection
- Approximately 70% of individuals with PUD are infected with H.pylori.
- Spread occurs through individual-to-individual contact (oral-oral or fecal-oral).
- H. pylori bacteria produce enzymes that reduce the effectiveness of mucous gel protection, and the host's inflammatory response to the bacteria contributes to gastric epithelial cell damage.
- While the gastric mucosa is the usual site for H.pylori infection, it also contributes to duodenal ulcers, possibly due to increased gastric acid production associated with the infection.
NSAID Contribution to PUD
- NSAIDs contribute to PUD through both systemic and topical mechanisms of injury.
- They interrupt prostaglandin synthesis by disrupting the activity of cyclooxygenase (COX) enzymes.
- COX-1 is crucial for maintaining gastric mucosal integrity, while COX-2 responds to inflammatory stimulation.
- COX-2-selective NSAIDs may be less damaging to the gastric mucosa due to their lesser effect on the COX-1 enzyme.
- Aspirin and many other NSAIDs cause topical injury by crossing the lipid membranes of gastric epithelial cells, damaging the cells themselves.
Ulcer Characteristics
- PUD ulcers can affect the esophagus, stomach, or duodenum, and can be superficial or deep, affecting all layers of the mucosa.
- Duodenal ulcers, the most common, usually develop in the proximal duodenum, close to the pylorus.
- They are sharply defined and typically less than 1 cm in diameter.
- Gastric ulcers are frequently found on the lesser curvature and near the pylorus.
- Gastric ulcers are linked to an increased risk of gastric cancer.
PUD Course
- PUD can be chronic, with periods of spontaneous remission and exacerbation.
- Exacerbations may be linked to trauma, infection, or other physical or psychological stressors.
Etiology and Risk Factors
- H.pylori infections often occur in childhood and can spread through unclean water and saliva.
- Chronic H.pylori infection and chronic use of NSAIDs, including aspirin, are the primary risk factors for PUD.
- Among NSAIDs, aspirin is the most ulcerogenic.
- Cigarette smoking is a significant risk factor, doubling the risk of PUD.
- Other risk factors include low socioeconomic status, crowded and unsanitary living conditions, unclean food or water, advanced age, a history of ulcers, family history of PUD, and concurrent use of other drugs (e.g., glucocorticoids, bisphosphonates).
Prevention
- Prevention strategies depend on the etiology of the ulcer.
- For H.pylori infection, good hand hygiene, clean water, and proper food preparation are important, but avoidance is difficult due to the commonality of infection and asymptomatic nature in many individuals.
- For patients with a history of long-term NSAID use, recommendations include adding histamine receptor antagonists, proton pump inhibitors (PPIs), or misoprostol to NSAID therapy, or switching to COX-2-selective NSAIDs.
- All patients starting long-term treatment with nonselective NSAIDs should undergo H.pylori testing, regardless of their risk level.
Peptic Ulcer Disease (PUD)
- Classic symptom is abdominal pain, described as gnawing, burning, aching, or hunger-like
- Pain typically occurs 2-3 hours after meals, in the middle of the night, and is relieved by eating
- Older adults may experience vague discomfort, chest pain, dysphagia, weight loss, or anemia
- Complications of PUD include hemorrhage, obstruction, and perforation
Hemorrhage
- Occurs in 10-20% of individuals with PUD
- Most frequent complication in older adults
- Signs include blood in stool (obvious or occult), hematemesis, fatigue, weakness, dizziness, orthostatic hypotension, and hypovolemic shock
- Slow bleeding can lead to anemia
- Sudden and severe bleeding can lead to hematemesis, melena, or hematochezia, and signs of hypovolemic shock
Obstruction
- Gastric outlet obstruction impairs gastric outflow
- Can result from edema, smooth muscle spasm, or scar tissue surrounding the ulcer
- Symptoms include epigastric fullness, accentuated ulcer symptoms, nausea, and vomiting
- Complete obstruction leads to vomiting
- Vomiting results in loss of hydrochloric acid, sodium, and potassium, leading to fluid and electrolyte imbalance and metabolic alkalosis
Perforation
- Most lethal complication
- Occurs when the ulcer penetrates the mucosal wall
- Gastric or duodenal contents enter the peritoneum, causing inflammation and peritonitis
- Immediate chemical peritonitis from gastric contents is followed by bacterial peritonitis within 6-12 hours
- Symptoms include severe upper abdominal pain radiating throughout the abdomen and possibly to the shoulder, rigid and boardlike abdomen, absence of bowel sounds, and signs of shock
- Older adults may present with confusion and atypical symptoms, leading to delays in diagnosis and treatment
Zollinger-Ellison Syndrome
- Form of PUD caused by a gastrinoma (gastrin-secreting tumor)
- Gastrinomas are usually malignant
- Gastrin stimulates secretion of pepsin and hydrochloric acid
- Increased gastrin levels lead to hypersecretion of gastric acid, causing mucosal ulceration
- Ulcers typically affect the duodenum but can involve the stomach or jejunum
- Characteristic ulcer-like pain is common
- Duodenum's protective buffering mechanism is overwhelmed by high levels of hydrochloric acid, resulting in diarrhea and steatorrhea
- Complications include bleeding and perforation
- Persistent diarrhea can lead to fluid and electrolyte imbalances, particularly potassium and sodium loss
Clinical Therapies for PUD
-
H. pylori infection or NSAIDs:
- PPI in combination with two antibiotics to eradicate infection
- Bismuth-containing product with two antibiotics and a PPI
- Retreatment requires using different antibiotics
- Discontinue or reduce dose of NSAIDs, if possible, or switch to less ulcerogenic NSAID
- H2-receptor agonists
- Mucosa-protecting agents
-
Hemorrhage:
- Monitor for anemia
- Monitor amount of vomitus
- Provide IV fluids as ordered
- Provide PUD treatment as ordered
- Surgery may be needed; ensure patient is NPO and understands the procedure
- Provide postoperative care as needed
-
Obstruction:
- Monitor electrolytes
- Provide IV fluids as ordered
- Surgery may be needed; ensure patient is NPO and understands the procedure
- Provide postoperative care as needed
-
Perforation:
- Early treatment reduces morbidity and mortality
- Monitor for signs and symptoms of infection
- Administer pain control as needed
- Insert and/or monitor NG tube
- Provide IV fluids as ordered
- Provide PUD treatment as ordered
- Surgery may be needed; ensure patient is NPO and understands the procedure
- Provide postoperative care as needed
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Description
This quiz provides an overview of Peptic Ulcer Disease (PUD), including its causes, prevalence, and types of ulcers. It also discusses the pathophysiology of PUD and the factors that increase the risk of developing ulcers. Test your knowledge on this chronic gastrointestinal condition.
