Peptic Ulcers

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 occur five times more commonly on the duodenum.

Duodenal ulcers occur most between the ages ono and 55. Gastric ulcers occur more commonly between the ages of 55 and 70.

Causes

Many factors make you more likely to have an ulcer.

• It often seems to run in families.
• Smoking increases the risk.
• Heavy drinking.
• Certain drugs eg aspirin and other anti-inflammatory drugs .
• We now know that a large percentage of people who have ulcers have a germ (Helicobacter pylori) in their stomach which they probably picked up many years previously, which makes the ulcer more likely to occur and more difficult to heal.

Signs and symptoms

Burning pain is the most common symptom of a peptic ulcer. The pain is caused by the ulcer and is aggravated by stomach acid coming in contact with the ulcerated area. The pain typically may:

• Be felt anywhere from your navel to your breastbone
• Last from a few minutes to many hours
• Be worse when your stomach is empty
• Flare at night
• Often be temporarily relieved by eating certain foods that buffer stomach acid or by taking an acid-reducing medication
• Come and go for a few days or weeks

Less often, ulcers may cause severe signs or symptoms such as:

• The vomiting of blood - which may appear red or black
• Dark blood in stools or stools that are black or tarry
• Nausea or vomiting
• Unexplained weight loss
• Chest pain

Diagnosis

Patients with dyspepsia may have an upper GI series to diagnose peptic ulcers. For patients with confirmed gastric ulcers, an upper endoscopy should be performed within 8 to 12 weeks to distinguish between benign and malignant disease. An endoscopy should also be performed in patients with GI bleeding to identify areas of ulceration. In patients 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 decreased hemoglobin and hematocrit values from GI bleeding.

Treatment

H. pylori can be treated with a number of triple-combination therapy regimens. The most effective agents include clarithromycin, metronidazole, amoxicillin, tetracycline, and proton pump inhibitors. However, none of these drugs are effective in eradication as a monotherapy.

Current recommendations include treating every patient at least once to eradicate H. pylori because the infection may occur even with other causes, such as NSAID use. Initial treatment includes tetracycline, bismuth subsalicylate, and metronidazole. Amoxicillin
may be tried as an alternative treatment.

Pharmacologic treatments include antisecretory agents, such as proton pump inhibitors and histamine 2 (H2)-receptor antagonists. Proton pump inhibitors (such as omeprazole or lansoprazole) work by binding the acid-secreting enzyme hydrogen/potassium ATPase by
inactivating it. H2-receptor antagonists (such as cimetidine, ranitidine, famotidine, and nizatidine) inhibit histamine binding to H2 receptors on the gastric parietal cell, which in turn decreases acid secretion. Drug therapy, which protects the mucosa, includes prostaglandin analogs (misoprostol) and antacids. Prostaglandin analogs may be given to patients taking NSAIDs to suppress ulceration.

Gl bleeding may be treated by giving H2-receptor antagonists I.V. as a continuous infusion. Upper endoscopy is preferred as a diagnostic tool when Gl bleeding is present. An injection of epinephrine or saline to surround the ulcer can be performed at endoscopy to
stop the bleeding. Cautery may also be used for hemostasis.

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.

Prevention

• Don't smoke or chew tobacco.
• Limit alcohol.
• Eat small meals regularly.
• Avoid aspirin, ibuprofen, and naproxen. Try acetaminophen instead.
• Avoid any foods which seem to bring on pain.