Peptic Ulcer Disease

Peptic ulcer disease

Definition

• An ulcer in the lining of the stomach or duodenum, where hydrochloric acid and pepsin are present, is referred to as a peptic ulcer.

• When the ulcer is in the stomach, it is called a gastric ulcer.

• When the ulcer is in the duodenum, it is called a duodenal ulcer.

Causes• Infection with Helicobacter pylori.– by disrupting mucosal integrity.

• Anti-inflammatory drugs (NSAIDs). – decrease in prostaglandin production resulting from

the inhibition of cyclooxygenase.• Cigarette smoking. – can affect gastric mucosal defense adversely.

• Zollinger-Ellison syndrome (rare).– profound hypersecretion of gastric acid.

• Period of stress.

Clinical picture

• Gastric ulcer pain is occurs shortly after meals.• Duodenal ulcer pain occurs 2-3 hours after

meals and at night. • The pain is located in the epigastrium, may

radiate to the back.• Patients with bleeding gastric ulcers may

shows hematemesis, melena, orthostatic syncope.

Symptoms

• Epigastric pain can be sharp, dull, burning, or penetrating.

• Feeling of hunger.• Excessive salivation. • Vomiting relieves the pain in gastric ulcer. – Acid to taste and smell.

• Appetite is increased. • Bloating or nausea after eating.

Location of ulcers

Gastric ulcers: (pain in epigastrium above navel)•Lesser curvature (common)•Cardiac region (least)– Pain around xiphoid process

•Pyloric antrumDuodenal ulcers: (epigastria pain to right median line)•Bulb (common)•Pyloric•Postbulbar •Extrabulbar

Abdominal examination

• The abdomen doesn't rise and fall with respiration.

• Palpation:– Tender on surface palpation– Muscles strained(Mendel’s test)– Late splashing sound to right median line.

• Percussion, there may be obliteration or diminished liver dullness.

• Auscultation, bowel sound may be reduced.

Stages of peptic ulcer

I. Prelude to ulcer .– Marked disorder of nervous system and

gastroduodenal dysfunction.

II. Organic changes.– Gastoduodenitis.

III. Formation of ulcer.IV. Development of post-ulcerous processes.

Complications

• Haemorrhages – melena, weakness, orthostatic syncope,

and hematemesis.• Ulcer perforation – resulting in acute peritonitis.

• Gastric obstruction – increasing abdominal pain, vomiting of undigested

or partially digested food, diminished appetite, and weight loss.

Differences between gastric ulcers and duodenal ulcers

Gastic ulcers Duodenal ulcers

Pain increases after eating. Pain decreases after eating.

Pain occurs early after meal. Pain occurs late after meal (at night).

Occurs in the stomach. Occurs in the duodenum.

Common in elderly patients. Common in younger patients.

Vomiting relieves pain. Eating relieves pain.

Imaging studies

• Duodenal ulcer• Gastric ulcer on lesser curvature.

Imaging studies

• Ulcer crater in the lesser curve.

• Posterior wall duodenal ulcer.

Gastric carcinoma

Risk factors:1.Diet.2.Helicobacter pylori infection.3.Previous gastric surgery.4.Pernicious anemia.5.Adenomatous polyps.6.Chronic atrophic gastritis.7.Radiation exposure.8.Smoking.9.Genetic factors.10.Obesity.

Characteristics

• Age of onset : around 50-70 years of age• Loss in appetite.• Loss of weight.• Gastric outlet obstruction– Tumor is at the pyloric antrum.

• Dysphagia– If the tumour is at the cardiac region.

Clinical picture

• Pallor, cachexia and probably jaundice.• Severe wasting over the hands and face.• Presence of jaundice indicates liver

metastases.

Symptoms

• In the early stages of gastric cancer:– Indigestion and stomach

discomfort.– A bloated feeling after

eating.– Mild nausea.– Loss of appetite.– Heartburn.

• In advanced stages of gastric cancer:– Blood in the stool.– Vomiting.– Weight loss – Stomach pain.– Jaundice– Ascites – Trouble swallowing.

Abdominal examination

• Inspection : severe wasting. May be distended due to malignant ascites.

• Palpation : – tenderness over the epigastric region. – deep palpation reveals a hard, irregular mass. – enlarged stomach with succussion splash.

• Percussion : shifting dullness if there is malignant ascites.

Imaging

Gastroscopy• Gastric carcinoma at

antrum of stomach.

X-ray (single contrast barium)• Polypoid carcinoma

Duodenum Cancer Duodenum cancer is a rarely observed gastrointestinal cancer. Causes:•High fat diet•Celiac disease•Crohn's disease•Familial adenomatous polyposis (FAP) infection•Muir-Torre syndrome•Puetz-Jeghers•Duodenal Ulcer•Juvenile Polyposis Syndrome

Cancer Symptoms• Pain • Nausea• Vomiting• Boating of abdomen after consumption of food• Blood in stool• Abdominal swelling• Unexplained weight loss• Abdominal pain in the middle region• Heartburn• Acid reflux• Fatigue

Diagnosis

1. Physical examination.2. Fecal occult blood test (stool sample).3. Other examinations:– Blood chemistry studies– Liver function tests– Abdominal x-ray– Barium enema– MRI – CT scan

Imaging

• Spot radiograph from double-contrast barium study shows sessile, slightly lobulated 1.3-cm polyp (arrows) in duodenal bulb.

References 1. McLeod’s Clinical Examination 10th edition, Munro

Campbell, Churchhill Livingstone, ISBN 0-443-06186-6.2. Internal Diseases Properdeutics, V.T Ivashkin, A.V

Okhlobystin, Geotar Media, ISBN 5-9704-0070-X.3. Properdeutics of Internal Diseases, V.Kh Vasilenko.4. http://www.wrongdiagnosis.com/5. http://emedicine.medscape.com/6. http://www.medicinenet.com/script/main/hp.asp7. http://www.cancer.gov/8. http://www.umm.edu/9. http://www.merckmanuals.com/