Peptic Ulcer Disease

Epidemology
Males: 10%, x3 duodenal
Female: 5%, more likely gastric

Symptoms
(NB not well correlated to actual endoscopic findings)
Relapsing, remitting
Epigastric pain
 - Worse at night & 1-3hrs post food
 - Improves with antacids & immediately post-food
 - Can radiate to chest/neck
also...
Nausea
Vomiting
Severe
Opiate-worthy pain
Haematemesis
Melaena
Weight loss
Anaemia
(the last few = ?malignancy)
Acute perforation
Peritonism
Shock

Aetiology
H. Pylori
 - 95% of Duodenal PUD
 - 75% of Gastric PUD
NSAIDs
Smoking
Alcohol
Hypercalcaemia
Zollinger-Ellison Sydrome

Pathogenesis
Imbalance b/w mucosal defences and effects of pepsin and acid
Pepsin potentiated by hyperacidity
Additive Aet Fx

Ix
98% of ulcers in duodenum (75%) & stomach (25% - * on lesser curve)
10-20% of those with gastric ulcer also have a duodenal ulcer
Other sites
GOJ
gastrojejunostomy sites
jejunum (Zollinger-Ellison syndrome)
Meckels diverticulum

Macro Dx
Solitary
<4cm
Round
Punched out mucosal defects
Vertical walls (NB heaping at edge = carcinoma)
Base = musc muc/vessels/omentum (if perforation)

Scarring 
puckered mucosa
radiating from central ulcer
*chronic gastritis in background (not common with acute erosive gastritis/stress ulcers)

Micro
Variable
Active necrosis/chronic ulceration/healing

Active ulceration
1) superficial fibrinoid necrosis with mucosal excavation
2) mixed inflammatory cell infiltrate within lamina propria
3) active granulation tissue
4) underlying fibrosis

Cx
Recurrent morbidity
Bleeding 15-20% (25% of ulcer deaths)
Perforation 5% (66% of ulcer deaths)
Obstruction 2%
Anaemia
Intractable pain
Malignancy (increased risk prob from underlying gastritis/malig. lesion mistaken as benign ulceration)