Peptic Ulcer Disease – Symptoms, Treatment, Pathophysiology

What is Peptic Ulcer Disease?

Peptic ulcer disease or simply peptic ulcer is the presence of ulcerations in the gastrointestinal tract, which is characterized by being acidic and extremely painful. Ulcerations in the GIT involve mucosal erosions of more than 0.5 cm.


Peptic Ulcer Disease


Peptic ulcer can occur in various parts of the gastrointestinal tract. Peptic ulcers can also be classified according to severity. These include:


Types according to Location

  • Duodenal ulcer

This occurs on the duodenum just after the pylorus of the stomach.

  • Gastric ulcer

This type of ulcer occurs on the stomach itself, particularly on the lower half portion.

  • Esophageal ulcer

Esophageal ulcer occurs in the esophagus itself.

A small percentage of gastric ulcers are caused by cancerous tumors. On the other hand, duodenal ulcers are commonly benign or non-cancerous.

Symptoms & Signs of Peptic Ulcer Disease

Symptoms and signs of peptic ulcer disease include:

  • Abdominal pain

The classical sign of ulcer is epigastric pain, which occurs with regards to meals. Gastric ulcers involve severe pain during mealtime, while duodenal ulcers involve pain after three hours of eating. Pain is usually increased during meal time with gastric ulcers because of increased gastric acid secretions that lead to further irritation of the stomach. On the other hand, when the food already moves down the duodenum after two to three hours, pain is experienced by patients with duodenal ulcers. Pain involved may be characterized as gnawing or similar to the feeling when one feels hunger. The pain may also radiate up to the sternum because of acids in the esophagus.

  • Nausea and vomiting

Severe acidity of the stomach that irritates the gastric or duodenal lining causes feelings of nausea and vomiting. There is also copious vomiting because of increased production of stomach acids.

  • Abdominal bloating

Ulcerations also cause more gas production leading to bloating and fullness.

  • Loss of appetite

Intense pain with nausea and vomiting often leads to anorexia especially when gastric ulcer pain is aggravated by eating.

  • Waterbash

This is the presence of sudden increase in saliva in the mouth to neutralize the gastric acids that went up the esophagus.

  • Hematemesis

Hematemesis is the presence of blood in the vomitus as a result of bleeding in the ulcers.

  • Melena

Melena is characterized by presence of black tarry stool as a result of bleeding in the upper gastrointestinal tract. This may result from bleeding in the ulcers in the stomach, esophagus or duodenum. The blood has already been oxidized as it travels down the gastrointestinal tract, thereby presenting as black and tarry.

Pathophysiology

The stomach lining is maintained by the gastric mucus to prevent irritation, however, because of certain factors, the stomach lining becomes irritated for prolonged periods. The stomach acids are very potent in irritating the stomach lining especially when the stomach is empty. When this happens, a wound may result, which may increase in size and become ulcer. Once the ulcer has developed, this causes inflammatory response in order to aid in tissue repair. Inflammatory mediators cause pain in the area. Consistent irritation by medications or irritating foods can aggravate the condition and lead to perforation or hemorrhage. The presence of perforation may lead to peritonitis and may become life-threatening because of sepsis and profuse bleeding.


Causes & Risk Factors

Causes of peptic ulcer disease include:

  • Helicobacter pylori infection

Up to 90% of peptic ulcers are due to the colonization of H. pylori in the mucosa of the GIT.  The infection produces chronic inflammation and gastritis that eventually leads to increased gastrin formation that may erode the mucosa leading to peptic ulcer.

  • Prolonged NSAID use

The lining of the stomach is protected by the mucus to prevent contact with the erosive acids. This mucus is regulated by prostaglandin. With the frequent use of NSAIDs, prostaglandin synthesis is impaired leading to reduced gastric mucus that protects the lining.

  • Alcoholism and smoking

These contribute to peptic ulcer disease along with H. pylori infection.

  • Diseases

Presence of Zollinger Ellison Syndrome causes the development of gastrin-secreting tumors, which increases the risk for severe ulcers.

  • Stress

Physiologic as well as emotional and psychological stress increases the production of gastric acids that increases risk for the development of ulcers.

Treatment & Diet

Treatments for peptic ulcer disease include those that help the erosion to heal as well as those that reduce the symptoms. These include:

Anti ulcer medications

Medications that help heal the GIT lining are given to prevent further irritation by the stomach acids, which include:

Antacids

Antacids such as magnesium hydroxide or aluminum hydroxide are given to neutralize the stomach content and reduce the acidity. These are given after meals.

H2 receptor antagonists

When histamine binds to its receptor sites in the gastric mucosa, there is an increased production of gastric acids. To prevent this, medications that block the receptor sites are given such as ranitidine. These medications are given before meals.

Proton pump inhibitors

Proton pump inhibitors such as sucralfate prevent the movement of hydrogen ions into the stomach so that binding to chloride are prevented, thereby preventing HCL production.

Prostaglandin analogues

Prostaglandin analogues such as Misoprostol are also given to reverse the effects of NSAIDs in reducing prostaglandin synthesis.

Antibiotics

Antibiotics are given such as amoxicillin, Clarithromycin, tetracycline and metronidazole to reduce H. pylori infection. These are given along with antiulcer drugs.

Bismuth Compound

Medications containing bismuth were also found to reduce infection by H. pylori.

Surgery

Surgery is usually indicated for patients who have perforated and bleeding ulcers. Surgery may involve clipping, cautery or injection of coagulants through endoscopy. Endoscopic hemostasis is performed to stop the bleeding in the ulcer and prevent hypovolemia.

Diet Modification

Diet modification is also important to prevent further initiation. Following surgery or the acute phase of disease, soft diet may be employed in order not to irritate the wounded lining of the stomach, esophagus or duodenum. The patient may progress to full diet when tolerated. However, alcohol and other irritating foods should be avoided to prevent recurrence of the ulceration.

Complications

Complications of peptic ulcer disease include:

  • Perforation
  • Peritonitis
  • Bleeding
  • Gastric outlet obstruction
  • Scarring of the gastric or duodenal mucosa
  • Penetration to other organs such as the pancreas and liver
  • Malignancy

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