Peptic ulcer disease Flashcards
What is ulcer?
Ulcer is a break in the continuity of epithelial surface
Where is peptic ulcer seen?
Peptic ulcer develops in/close to acid secreting areas in stomach (gastric ulcer) and proximal duodenum (duodenal ulcer). Can occur in the esophagus or in Meckel’s diverticulum.
Peptic ulcer : from lower esophagus > stomach/duodenum > rarely ileum adjacent to Meckel’s diverticlum
How does peptic ulcer occur?
- Peptic ulcers are produced by the imbalance between gastro-duodenal mucosal defense mechanisms and damaging forces of gastric acid and pepsin together with superimposed injury from environmental or immunologic agents (spicy food)
- mucous membrane lining the digestive tract erodes and cause break down of tissue which manifests clinically as burning pain in the the upper middle part of the abdomen
Gastric ulcer or duodenal ulcer is more common?
Duodenal ulcer
List the age group for gastric ulcer and duodenal ulcer
List the male:female predilection in which ulcer
Gastric ulcer :
Age group : 55-70 years old
M:F : Female predominance
Duodenal ulcer :
Age gorup : 30-55 year old
M:F : Male predominance
Etiology of peptic ulcer disease
- Helicobacter pyori infection (80%)
- Worsened by drugs (NSAID, Aspirin, Corticosteroid)
- Smoking, alcohol, stress, diet
- Acid hyper secretory state (Zollinger Ellison Syndrome : islet cell pancreas produce gastrin)
- Head injury, Intracranial tumor/infections : Cushing ulcer (increase in intracranial pressure lead to overstimulation of vagus nerve, increase in gastric acid secretion leading to gastro-duodenal ulcer
- Severe Burns : Curling’s ulcer (reduce plasma volume lead to ischemia and necrosis of gastric mucosa casing it to slough off)
Possible damaging actions of H.pylori ?
1) increase gastric acid secretion
2) loss of protective mucous layer
3) increased secretion of pepsinogen and gastrin
4) decreased duodenal bicarbonate secretion
NSAIDs induced ulcer
- long time use of NSAID are more commonly associated with gastric ulcers than duodenal ulcer
- complications of patient : more commonly ulcer related which can irritate the lining of stomach and small intestine
- Action : inhibit the production of enzyme cyclo-oxygenase (COX) that produces prostaglandins and these hormone like substances help protect stomach lining from chemical and physical injury
- Examples : aspirin, ibuprofen, naproxen, ketoprofen
- celecoxib, etorocoxib less likely cause gastric ulcer (COX 2 inhibitor)
Effects of smoking on peptic ulcer disease
- Increased rate of gastric emptying
- Diminished pancreatic bicarbonate secretion
- Decreased duodenal pH
- Reduced mucosal blood flow
- Inhibition of mucosal prostaglandins
Clinical features of peptic ulcer disease
- Recurrent epigastric pain which is burning pain and gnawing (hunger pain)
- may be symptomless
- occasional dyspepsia (indigestion)
- acid/water brash
- complications : hemorrhage, perforations, pyloric obstruction (stenosis) with vomiting
Symptoms of PUD
- Burning pain
- Nausea
- Unexplained weight loss
- Appetite changes
- Vomiting
- Low blood cell count (anemia)
- Frequent burping or hiccuping
- Bloating
- Water brash
- Hematemesis (vomiting of blood)
- Melena
- Blood in the stools
- Stomach pain wakes you up at night
- An early sense of fullness with eating
Gastric vs duodenal ulcer
Duodenal ulcer :
- burning, gnawing, aching, hunger-like pain, primarily in the epigastric region.
- pain may occur or worsen when stomach is empty, usually 2-3 hours after a meal
- can occur at night between 11pm and 2am when acid tends to be the greatest
- feel better when eat or drink and then worse 1 or 2 hours later (duodenal ulcer)
- Relieving factor is eating
Gastric ulcer :
- epigastric region
- pain soon after eating
- feel worse when you eat or drink
- not relieved by eating or taking antacids
- relieving factors is vomiting
Complications of peptic ulcer disease
- gastrointestinal bleeding : (most common complication)
ulcer erodes one of the blood vessels
— slow blood loss : anemia
— severe blood loss : hospitalization or blood transfusion - perforation : erosion in gastro intestinal wall by ulcer leads to spillage of stomach/intestinal content into the abdomina cavity.
— perforation at anterior surface of stomcah : acute peritonitis (initially chemical then later bacterial peritonitis
— first sign : sudden intense abdominal pain
—perforation at posterior : pancreatitis (pain often radiates to the back - Penetration : ulcer continues into adjacent organs (liver and pancreas)
- Scar tissue : scaring and swelling causes narrowing in duodenum and gastric outlet obstruction (pyloric stenosis).
—- patient often presents with severe vomiting (obstruction of food through digestive tract causing fullness easily and to vomit and lose weight.
Investigations done on peptic ulcer disease
1) Endoscopy (choice of investigation)
2) Barium studies (may be done before endoscopy)
3) Gastric acid/serum gastrin levels
4) Biopsy
5) Blood test (show anemia)
6) Stool (occult blood)
H.pylori can be diagnosed by
- non invasive tests: serology, fecal antigen assay, urea breath test
- invasive tests : biopsy urease test, histology, culture
Management of peptic ulcer disease
1) Dietary modifications (frequent small meals with no fried foods)
2) Smoking cessation
3) Alcohol moderation
