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Peptic Ulcer Disease

Overview

Peptic Ulcer Disease (PUD) is a discontinuity or break in the stomach's inner lining, a protective layer in the stomach, composed of mucus and bicarbonate that neutralizes the stomach’s acid secreted by the stomach mucosa. Peptic ulcers are common in the first part of the small intestine, or sometimes the lower esophagus.

The most common symptoms are burning sensation and pain in the stomach region. It is diagnosed by endoscopy and urease breath tests, and it is treated by medications and some surgical procedures when needed.

Causes

Among many causes of peptic ulcer disease, the most common is a bacteria known as Helicobacter pylori (H. pylori). These bacteria enter the body and live in the digestive tract and cause ulceration in the body. This makes it the most critical factor in peptic ulcer disease accounting for 90% of duodenal and 70 % of gastric ulcers.

Nonsteroidal anti-inflammatory drugs (NSAIDs) such as Aspirin, ibuprofen, and naproxen damage the gastric mucosal barrier, making it an essential etiological factor in 30% of cases of gastric ulcers. In some cases, they may be responsible for duodenal ulcers as well.

Contrary to popular belief, stress and spicy food do not cause peptic ulcers.

Types

There are two most important types of gastric ulcers;

  • Duodenal ulcers: When an ulcer is in the first part of the intestines, called a duodenum, it is a duodenal ulcer. 90 -95% of peptic ulcers are duodenal ulcers.
  • Gastric ulcers: when the ulcers are found in the stomach, it is called gastric ulcers; 30% of the peptic ulcers are gastric ulcers. Gastric ulcers may develop into cancers.

Epidemiology

The incidence of peptic ulcer disease has declined as the awareness about the risk factors has spread. The prevalence was higher in males before but now has come in equal ratios between males and females.

Risk Factors

The following risk factors are essential in causing the disease:

  • Family history: Peptic ulcers tend to run in families.
  • Helicobacter pylori: most important factor is this bacterium. It destroys the protective lining resulting in ulceration.
  • Smoking: It is one of the significant risk factors. Not only it causes ulcers, but it also decreases the chances of healing and increases the risk of recurrence.
  • Alcohol irritates the stomach lining, increasing the chances of ulceration.

Signs And Symptoms

Peptic Ulcer Disease causes the following signs and symptoms.

  • Epigastric Pain: this is the most common symptom. It feels like burning or gnawing pain that usually occurs after meals. Duodenal ulcer pain often awakens the person at night and is relieved by food and antacids, while this is not the case with gastric ulcers.
    Indigestion: some people may feel bloating, belching, and fatty food intolerance.
  • Chest Discomfort: people may also feel a burning sensation in the chest, usually known as heartburn.
  • Bleeding: these ulcers can sometimes bleed, causing black tarry stools called melena.
  • Anemia: due to blood loss, the patient may suffer from anemia and have the symptoms of fatigue and difficulty breathing on exertion.
  • Nausea/Vomiting: patients may also complain of feeling nauseated and occasionally vomiting.

Diagnosis

Your doctor will take a detailed history to ask about the possible risk factors causing the ulcers. But some tests are essential to confirm the presence and the type of ulcers;

  • Tests for Helicobacter Pylori Bacteria: your doctor may advise laboratory tests on blood, stool, or breath to find out the bacteria. Out of which, the Urease breath test is the most specific.
  • Endoscopy is a procedure of choice for the diagnosis of peptic ulcers. In this test, a flexible tube with the camera is inserted through your mouth to visualize the inside of the esophagus, stomach, duodenum. A biopsy can also be taken to detect H. pylori and gastric cancer.
  • Barium Meal X Rays: in this test, you are given to swallow barium meal, after which a series of x rays are taken that shows the ulcer. It is not used commonly now. 

Differential Diagnosis

  • Acute Cholangitis
  • Acute Gastritis
  • Acute Cholecystitis and biliary colic
  • Acute coronary syndrome
  • Gastroesophageal Reflux Disease
  • Esophagitis
  • Chronic Gastritis
  • Diverticulitis

Treatment

The treatment involves removing the causative factors, eradicating the bacteria, and controlling the acid secretion of the stomach.

  • Medicines to eradicate h.pylori bacteria: this includes a 14-day course of a combination of antibiotics including Amoxicillin, metronidazole, clarithromycin, or tetracycline.
  • Medicines to control acid secretion: H2 Receptor Antagonists are the first choice of therapy. They not only suppress acid secretion but also promote healing. ( Although Cimetidine may cause confusion in the elderly and gynecomastia and impotence in young males and the elderly, these drugs are generally safe). (PPI) proton pump inhibitors such as omeprazole are used in combination therapy for eradication of H. pylori and in treating reflux esophagitis.
  • Mucosal protective medicines: Drugs such as Sucralfate and Bismuth compounds enhance mucosal defenses. Misoprostol, a prostaglandin analogue, promotes ulcer healing by promoting bicarbonate secretion and halting stomach acid secretion. The side effects are abdominal pain and diarrhea. Misoprostol is not as effective as other anti-ulcer drugs.

Procedures

Surgical management is also an option if there is a risk for perforations and bleeding.

Types of operations

  • Partial Gastrectomy: this procedure involves removing the stomach area that secretes gastrin, which causes acid release. The complication of such a surgery is dumping, where a patient feels nausea and vomiting upon eating food. The patients will lose weight following this procedure.
  • Vagotomy: this involves cutting off the fibers of the Vagus nerves, which is also responsible for the acid release.

Prognosis

Peptic Ulcer Disease (PUD) has an excellent prognosis after the underlying cause is treated. Unfortunately, recurrence is standard, with rates exceeding 60% in most serious cases.