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

Peptic Ulcer Causes Examination Diagnosis and Treatment

Peptic Ulcer Types —

Gastric ulcer

  • Gastric ulcers occur later in life than duodenal ulcers usually around 6th 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.


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