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Brief Summary of Peptic ulcersGeneral MedicineAdd comments

Jul212011

Peptic ulcer is a disruption in the gastric or duodenal mucosa when normal defense mechanisms are

overwhelmed or impaired by acid or pepsin. Ulcers are circumscribed lesions that extend through

the muscularis mucosa. Ulcers are five times more common on the duodenum.

Causes

Researchers recognize three major causes of peptic ulcer disease: infection with Helicobacter pylori,

use of nonsteroidal anti-inflammatory drugs (NSAIDs), and pathologic hypersecretory states such as

Zollinger-Ellison syndrome.

H. pylori is the cause of the majority of duodenal and gastric ulcers. Following treatment with

standard therapies, 70% to 85% of patients have a documented recurrence (by endoscopy) within 1

year.

Other causes include the use of certain drugs, such as salicylates and other NSAIDs, which

encourage ulcer formation by inhibiting the secretion of prostaglandins (the substances that

suppress ulceration). Certain illnessessuch as pancreatitis, hepatic disease, Crohns disease,

Zollinger-Ellison syndrome, and preexisting gastritis are also known causes. Additionally, having

a type A personality increases autonomic nervous system effects on the gastric mucosa.

Predisposing factors

Ulcers are more common in smokers and those who regularly use NSAIDs. (Smoking increases theamount of hydrochloric acid in the stomach; nicotine reduces the bicarbonate content of pancreatic

secretions and also decreases the degree of acid neutralization.) Diet and alcohol dont appear to

contribute to the development of peptic ulcer disease. Its unclear whether emotional stress is a

contributing factor.

Signs and symptoms

Symptoms vary with the type of ulcer.

Gastric ulcers

Gastric ulcers are usually signaled by pain that becomes more intense with eating. The pain isusually constant because the gastric mucosa is sensitive to acid secretion. Nausea or anorexia may

occur.

Duodenal ulcers

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8/11/2019 Brief Summary of Peptic Ulcers

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Duodenal ulcers produce epigastric pain thats gnawing, dull, aching, or hunger-like. The pain

is relieved by food or antacids and typically recurs 2 to 4 hours later. Weight loss or vomiting is

typically a sign of malignancy or gastric outlet obstruction.

Well-localized midepigastric pain (relieved by food), weight gain (because the patient eats to relieve

discomfort), and a peculiar sensation of hot water bubbling in the back of the throat are other

reported signs.

Exacerbations tend to recur several times a year, then fade into remission. Vomiting and other

digestive disturbances are rare.

Complications

Both kinds of ulcers may be asymptomatic or may penetrate the pancreas and cause severe back

pain. Other complications of peptic ulcers include perforation, hemorrhage, and pyloric obstruction.

Diagnosis

A patient with dyspepsia may have an upper GI series to help diagnose a peptic ulcer. For a patient

with a confirmed gastric ulcer, an upper endoscopy should be performed to help distinguish between

benign and malignant disease. An endoscopy should also be performed in a patient with GI bleeding

to identify areas of ulceration. In a patient with a history of peptic ulcer disease, H. pylori may be

diagnosed with urease breath testing or serologic testing. H. pylori can also be diagnosed by biopsy

via upper endoscopy.

Other tests may disclose occult blood in the stools and a decreased hemoglobin level and

hematocrit from GI bleeding.

Treatment

H. pylori can be treated with a combination of agents and eradicated with antibiotics. Pharmacologic

treatments include antisecretory agents, such as proton pump inhibitors and histamine-2 (H2)-

receptor antagonists. Proton pump inhibitors work by binding to hydrogen-potassium adenosine

triphosphatase, located at the surface of gastric parital cells to block formation of gastic acid. H 2-

receptor antagonists inhibit histamine binding to H2receptors on the gastric parietal cell, which in

turn decreases acid secretion. Drug therapy, which protects the mucosa, includes prostaglandin

analogs and antacids. Prostaglandin analogs may be given to patients taking NSAIDs to suppress

ulceration.

GI bleeding may be treated by giving H2-receptor antagonists I.V. as a continuous infusion. Upper

endoscopy is preferred as a diagnostic tool when GI bleeding is present because an injection of

epinephrine or saline (to surround the ulcer) can be performed to stop the bleeding during the

procedure; cautery may also be used for hemostasis.

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Surgery is indicated for perforation of the ulcer, continued bleeding despite medical treatment, and

suspected malignancy. Surgical procedures for peptic ulcers and gastric outlet obstruction include:

vagotomy and pyloroplasty: severing one or more branches of the vagus nerve to reduce

hydrochloric acid secretion and refashioning the pylorus to create a larger lumen and facilitate

gastric emptying

distal subtotal gastrectomy (with or without vagotomy): excising the antrum of the stomach,

thereby removing the hormonal stimulus of the parietal cells, followed by anastomosis of the

remainder of the stomach to the duodenum or the jejunum.