Page 166 - Medicine and Surgery

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162 Chapter 4: Gastrointestinal system

Complications H. pylori negative (10%): Antisecretory therapy such
Perforation occurs much more commonly with duo- as H 2 receptor antagonists (first line) or proton pump

denal ulcers. It results in peritonitis and an acute ab- inhibitors are used. If the patient is taking NSAIDs
domen, free air is seen under the diaphragm on plain these should be stopped if possible.
erect chest X-ray. Patients require resuscitation and Gastric ulcer:
emergency surgery to locate and close the duodenal H. pylori positive (70%): Eradication therapy is used
perforations, a partial gastrectomy may be required in (see below) followed by antisecretory therapy for 2
gastric ulcers. months.
Haemorrhage may be slow and chronic presenting as H. pylori negative (30%): The majority of these are

anaemia. More rapid loss may cause melaena and hae- NSAID or aspirin induced. Standard antisecretory
matemesis. Peptic ulcer disease is the most common therapy should be given for 2 months and NSAIDs
causeofacuteuppergastrointestinalhaemorrhageand should be stopped if possible.
may cause hypovolaemia and shock. Acute bleeds re- Repeat endoscopy with biopsies is essential in all gastric
quire resuscitation to stabilise the patient and may ulcers until completely healed, as there may be an un-
require urgent endoscopic treatment (see page 147). derlying malignancy. If the ulcer does not heal within
Early endoscopy can reduce the risk of rebleeding by 6months then surgery should be considered.
injection or argon plasma coagulation of bleeding ul- In all patients with peptic ulcer disease who continue
cers. Surgery may be needed if bleeding is uncontrol- to require NSAIDs, long-term treatment with a proton
lable or endoscopy is unsuccessful. pump inhibitor (or misoprostol in gastric ulcers) should
Scarring of the pyloric region results in gradual de- be considered. In patients with rheumatoid arthritis or

velopment of outflow obstruction (pyloric stenosis). osteoarthritis a COX2 specific antagonist may be con-
The patient presents with upper abdominal distension sidered in place of the NSAID.
after meals and projectile vomiting. X-ray reveals a
distended stomach, barium meal is diagnostic. Fi-
broticstenosisrequiressurgicalinterventionfollowing Helicobacter pylori
treatment of any electrolyte imbalances resulting from
copious vomiting. Definition
H. pylori is a spiral bacterium which is implicated in the
causation of chronic gastritis, peptic ulcer disease, gas-
Investigations tric carcinoma and mucosal associated lymphoid tissue
Patients are investigated and managed as for dyspep- (MALT) lymphoma.
sia, i.e. patients under the age of 55 years without
‘alarm symptoms and signs’ (see under section Dys-
pepsia) are treated without endoscopy. Older patients Aetiology
and those with suspicious features should undergo en- The transmission of H. pylori is not fully understood;
doscopy to exclude malignancy prior to commencing however, intrafamilial clustering suggests person-to-
treatment. person spread and there is an association with lower
socio-economic class.
Management
Duodenal ulcer: Pathophysiology
H. pylori positive (90%): Patients should receive era- H.pylori bindstothegastricepitheliumbeneaththepro-

dication therapy (see below). If asymptomatic follow- tective mucus layer. It produces an enzyme that breaks
ing this treatment a further endoscopy is not neces- down the glycoproteins within the mucus. There are also
sary. If symptoms persist or recur (or in all patients changes in the secretory patterns within the stomach
initially presenting with complications) a urea breath along with toxin-mediated tissue damage. Initial infec-
test should be performed at 4 weeks and further erad- tion causes an acute gastritis which rapidly proceeds to
ication therapy used if positive. If negative clinical re- chronic inflammation. Prolonged inflammation results
evaluation is necessary. inmetaplasiaandpredisposestodysplasiaandneoplasia.