Peptic Ulcer

• Peptic Ulcer Causes Examination Diagnosis and Treatment

An ulcer is a disruption of mucosal lining of stomach and or duodenum due to active inflammation. Ulcers are usually chronic in nature. Peptic ulcer disease is a common illness, affecting about 10% of men and 5% of women during their lifetimes

Agents which may damage the mucosa

• · Acid
• · Pepsin
• · Bile acids
• · Pancreatic enzymes
• · Drugs
• · Bacteria.
• Both exogen9us and endogenous substances attack the mucosa. ‘
• The mucosal’defence consists of pre-epithelial, epi­thelial and sub-epithelial layers.
• There is a mucoLl bicarbonate layer which protects the mucosa.
• Bicarbonate secretion is stimulated by calcium, pros­taglandins, cholinergic input, and acidification.
•  Peptic ulcer disease includes gastric and duodenal ul­cers.
•  Ulcers are defined as a break in mucosal surface more than 5 mm in size.

Peptic Ulcer Types —

Gastric ulcer

• Gastric ulcers occur later in life than duodenal ulcers usually around 6^th decade.
• Gastric ulcers are more common in males.
• Found distal to junction between antrum and acid secreting mucosa.
• May be malignant.
• There may be H. pylori infection.
• Cause may be NSAIDs and H. pylori infection. Gastric acid may be normal or decreased. There is impairment of mucosal defence. There is delayed gastric emptying of solids.
• Less common than duodenal ulcer in absence of nonsteroidal anti-inflammatory drugs (NSAIDs)
• Commonly located along lesser curvature of the antrum near the incisura and in the prepyloric area
• H. pylori is also called Campylobacter pyloridis.
• H. pylori can also cause lymphoma and gastric ad­enocarcinoma.
•  In gastric ulcers discomfort is precipitated by food.
• Nausea and weight loss are seen in gastric ulcers.

Duodenal ulcer

• Duodenal ulcers are more common than gastric ul­cers.
• Most common in first part of duodenum within 3 cm of pylorus.
• Usually less than 1 cm diameter. ~ Giant ulcer may be 3-6 cm.
• Sharply demarcated and sometimes deep. Base of ulcers shows eosinophilic necrosis.
• Most common form of peptic ulcer
• Usually located in the proximal duodenum
• Multiple ulcers or ulcers distal to the second portion of duodenum raise possibility of Zollinger-Ellison syndrome.
• Common causes are H. pylori infections and NSAIDs~ Gastric acid secretion is increased.
• There is increased gastric emptying of liquids. Bicarbonate secretion is decreased.

Esophageal ulcers

• Located in the distal esophagus and usually secondary to gastroesophageal reflux disease (GERD); also can be seen with Zollinger-Ellison syndrome

Peptic Ulcer Clinical Features

• · Abdominal pain.
• · In NSAIDs-induced ulcers there may be bleeding, perforation, obstruction.
• · Epigastric pain, burning, gnawing pain.
• · Hunger pains.
• · Typical pain occurs 90 minutes to 3 hours after meal.
• · Relieved by meals or antacids.
• · Pain occurs between midnight and 3 AM and is so severe that the patient wakes up.
• · Dyspepsia is a common symptom.
• · In endoscopy-ulcers, ulcer crater and gas­troduodenitis are seen.
• · When complications occur there is dyspepsia.
• · Pain is not relieved by food or antacids, pain radiates to back in penetrating ulcers.
• · There may be pancreatitis.
• · There is constant nausea and vomiting.
• · Perforation is suggested by generalized and sud­den onset severe abdominal pain.
• There may be bleeding from the ulcers giving rise to’ • tarry stools or coffee-ground vomitings.

Peptic Ulcer Risk Factors

• H. pylori infection
• NSAID use
• Smoking cigarettes
• Family history of ulcers
• Zollinger-Ellison syndrome
• Medications: Corticosteroids (high-dose and/or prolonged therapy),

Peptic Ulcer Examination Diagnosis

• • Epigastric tenderness.
• Pain to the right of midline.
• Tachycardia, dehydration, orthostatic hypoten­sion due to vomiting or blood loss.
• Tender board-like (rigid) abdomen due to perfo­ration.
• Gastric outlet obstruction is indicated by pres­ence of succussion splash (splashing sound from the abdomen on shaking the body).

Peptic Ulcer Complications of Peptic ulcer disease

• 1. Gastrointestinal bleeding – Common in elderly and due to use of NSAIDs.
• 2. Perforation – Common in elderly, and use of NSAIDs.
• Duodenal ulcer penetrates into pancreas lead­ing to pancreatitis.
• Gastric ulcers penetrate into left liver lobe.
• 3. Gastric outlet obstruction – Occurs in prepyloric region. There is loss of appetite, nausea, vomit­ing, pain after meals and weight loss.

Peptic Ulcer Diagnosis

• · Barium study
• · Endoscopy
• · Detection of H. pylori
• · Serum gastrin and gastric acid analysis.
• Test for detection of H. pylori
  • Rapid urease, histology, culture, serology, urea breath test, stool antigen.

Peptic Ulcer Treatment

• 
  

  Acid suppressing drugs

   

  • Antacids – 100 meq/L given 1 and 3 hours after meals and at bed time.
  •  H₂ receptor antagonists:
  • Cimetidine – 400 mg BD
  • Ranitidine – 300 mg HS
  • Famotidine – 40 mg HS
  • JProton pump inhibitors:
  • Omeprazole 20 mg/day
  • Lansoprazole 30 mg/day
  • Rabeprazole – 20 mg/day
  • Pantoprazole – 40 mg/day
  •  ucosal protective agents:
  • Sucralfate 19m QID
  • Prostaglandin analogue (misoprostol 200IJg QID) Bismuth-containing compounds
  • H₂ receptor antagonists.
• 
  

  Therapy of Helicobacter pylori

   

  • Multiple drugs are used in combination therapy be­cause single agent is not effective.
  • Different regimens are:
  •  Bismuth subsalicylate + Metronidazole
  • Tetracycline
  • Ranitidine bismuth citrate +
  • Tetracycline
  • Metronidazole ..7 Omeprazole
  • Clarithromycin
  • Metronidazole/ Amoxici lIin
  • 500 mg qid 400 mg bd
  • 500 mg bd 20 mg bd
• 
  

  Surgical therapy

   

  • For refractive ulcer, GI bleeding, perforation, and gas­tric outlet obstruction.
  • For duodenal ulcers, operations performed are vago­tomy, pyloroplasty and gastrojejunostomy .

Zollinger-Ellison Syndrome

• There is severe peptic ulcer diathesis due to gastric acid hypersecretion. This is due to gastrinoma which is a non-betacell endocrine tumor.