Ulcer Disease Flashcards
What is peptic ulcer disease?
This is presence of profound loss of substance affecting the mucosa of the stomach and/or the duodenum reaching beyond the muscularis mucosa up to the muscularis layer due to environmental gastric acid secretion.
Etiology of Peptic ulcer
Common causes
- H.pylori
- NSAIDS and ASAs
Uncommon causes
- gastrinoma(zollinger-Ellison syndrome)
- hyperplasia of antral G cells
- Viral infections
- vascular insufficiency
- radiation
- Chrons disease
- Type 2 amyloidosis
Pathogenesis of peptic ulcer
Disbalnce between protective and afressive factors
-inflammatory and immunologic response triggered in infected patients to the level of gastric and duodenal mucosa
-release of pro inflammatory cytokines e.g IL-8 , TNF-alpha
- acute and chronic gastritis occur reducing the thickness and quality of the mucosal layer
-gastric hyper secretion occurs due to decrease in density of the antral D cells(delta cells which release somatostatin) therefore decreasing somatostatin release which determines loss of inhibitory stimulus
-in result hypergastrenemia stimulates parietal cells causing increase in acid secretion which further decrease ph in the stomach lumen and duodenum
-Duodenal gastric metaplasia occurs
-this cause failure of the duodenal mucosa to secrete bicarbonate thus causing duodenitis and later duodenal ulcer onset
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What are the complications of peptic ulcer disease?
There are four main complications
- Bleeding
- Perforation
- Penetration
- Obstruction
- pyloroduodenal stenosis
- Malignization
Bleeding
- the most common
- ulcers from NSAIDs more likely lead to bleeding than those by H.pylori
- elderly people and those with underlying conditions like cardiac etc are more at risk
Bleeding as a complication
Due to vessels erosion. Occult bleeding is asymptomatic, revealed only by Gregersen’s reaction.
Severe bleeding is revealed in 10%, both in duodenal and gastric ulcers. Symptoms:
- vomiting (by coffee groundings – haematin complex with Cl ions) - maelena – fluid dark stools (FeS) – in case of bleeding >180 ml
- general symptoms:
• blood loss 350-400 ml – mild nausea, dry mouth, weakness
• blood loss is more severe – cold perspiration, tachycardia, hypotonia, soft small, sometimes filiform pulse.
• 1 and more liters – haemorrhagic shoke
- disappearing of pain – Bergman’s sign nd - decrease of RBC in blood – end of 1 day – 2
day (haemodilution)
Bleeding as a complication
Due to vessels erosion. Occult bleeding is asymptomatic, revealed only by Gregersen’s reaction.
Severe bleeding is revealed in 10%, both in duodenal and gastric ulcers. Symptoms:
- vomiting (by coffee groundings – haematin complex with Cl ions) - maelena – fluid dark stools (FeS) – in case of bleeding >180 ml
- general symptoms:
• blood loss 350-400 ml – mild nausea, dry mouth, weakness
• blood loss is more severe – cold perspiration, tachycardia, hypotonia, soft small, sometimes filiform pulse.
• 1 and more liters – haemorrhagic shoke
- disappearing of pain – Bergman’s sign nd - decrease of RBC in blood – end of 1 day – 2
day (haemodilution)
Treatment:
- Rest, cold on the epigastrum, Vicasol and Decinon infusion and Ranitidin,
Famotidin or Omeprosol (the last one – 40-80 mg) i.v. bolus injection; per os – 5% acidum ε-aminocapronicum 5%, Maalox etc. Polyglucin (volume- replacing treatment).
- Hospitalization to surgical department
- Urgent endoscopy with diathermy or laser coagulation of the vessel,
Sucralfat may be placed on the ulcer zone
Perforation as a complication
- occurs in 5% of patients with peptic ulcer
- mostly corresponds to duodenal ulcers on the anterior wall of the duodenal bulb and 40% gastric ulcers in the lesser curvature
- free perforation into the peritoneal cavity is dangerous
- it usually appears as sudden, abdominal pain located in the epigastrium which may radiate to the back or become diffuse
- associated with acute shock suggests a complicated ulcer perforation with peritonitis
- the patient remains motionless and thighs flexed on the abdomen giving the impression of gravity
On examination;
- hard , rigid abdomen is seen with rebound
- auscultation shows increased intestinal noises and as the condition progresses they diminish and finally almost disappear
- abt 70% cases present visible pneumoperitoneum
Etiology is multi factorial e.g alcohol, tobacco,h.pylori,NSAIDs, chronic cockaine abuse.
Perforation into abdominal cavity:
- severe “knife-like” pain coinciding with the moment of perforation and st
gastric or duodenal masses appearance in abdominal cavity; during the 1
hours the pain is in upper abdomen, than becomes diffuse
- body position with legs close to the abdomen
- muscular tension (up to board-like abdomen due to peritoneum irritation)
- Jober sign – tympanic percussion sound at the place of the liver dullness
zone due to the gas in abdominal cavity; gas presence is confirmed by X-
ray.
- Additional signs are stools and gases retention and vomiting (the last re-vealed in 20% of patients)
Periods: - pain shock - visible well-being - peritonitis Urgent surgery is indicated
Penetration as a complication
-occurs when the ulcer crosses the wall of the stomach or duodenum but instead of opening into the peritoneal cavity it opens into another organ
Clinical presentation
- severe and persistent pain which is not relieved by eating and wakes the patient up at night
- radiation to the back when the ulcer penetrated to the pancreas or right upper quadrant when penetration is to the gastrohepatic omentum
- rarely penetrating ulcers form fistula between the duodenum and bile duct (chole doco -duodenal fistula) or between the stomach and colon
X-ray sign: deep ulcer with decreased mobility, sometimes very narrow ulcers Endoscopy: round or polygonal, deep ulcers.
In case of confirmed penetration, operative treatment is indicated; if not confirmed – active drug treatment may be used.
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Obstruction as a complication
- uncommon
- ulcers in pyloric channel and duodenal bulb cause obstruction
- it occurs as a result of swelling and oedema accompanying active ulceration or the healing process of the ulcer and shrinkage
Main symptoms
- nausea
- vomiting
- early satiety
- anorexia
- vomiting 30 to 60 minutes after meals and patients are often satisfied for for hours after meals
On clinical examination
-may show signs of thinning , dehydration and splash produced by sir and liquid retained within the distended stomach
Pyloroduodenal stenosis as a complication
May be due to scar of inflammation and spasm.
If by spasm:
- numerous vomiting, at first by remaining food masses, then by excessive acidic fluid
- every attempt of eating or drinking leads to vomiting at the same moment
- fluid loss symptoms
Stenosis due to scar formation
Symptoms develop during some years. Stages of compensation:
- compensated: severe heartburns dominate, so frequent use of antacids is necessary
X-ray: segmented peristaltics; food evacuation is unchanged subcompensation:
- Severe vomiting, sensation of heaviness in epigastrium with improvement after vomiting, so the last one is often provoked by patient.
- Progressive loss of body weight
- Objective: splash sound in epigastrium during palpation
X-ray: hypersecretion in the morning before eating; peristaltic is present, but becomes less active with time; barium retention time in stomach is up to 4-6 hours and more
Decompensation (1-2 years after compensation):
- severe stenosis with food retention for several days
- improvement after probe use to remove the food masses - electrolyte disorders
- decompensated alkalosis
- dry skin
- cramps – gastric tetany
Subcompensated and decompensated stenosis are indication to surgical treatment preceded by the electrolytes and proteins metabolism correction.
In inflammatory stenosis atropine 0.1%-1-2 ml injection or that of Metacin 0.1% - 4 -6 ml daily may be used, more effective is modern H2-blockers (Famotidin, Ranitidin) and Omeprasol administration.
Additionally prokinetics – Mothilium may be administrated.
Malignization as a complication
This is a very severe complication
What is the clinical picture of peptic ulcer disease?
- Pain
Characteristics
a.Localisation in the epigastrium
For gastric ulcer- mostly in the center and to the left from linea mediana
Duodenal ulcer- in pyloroduodenal zone
b. intensity
- from very mild to severe
- patient tends to press abdomen with fist and immediately needs to take pain relieving drugs
c.when does it appear
1st hr after meals or 1.5-3hrs after meals
Fasting pain relieved with food intake
Nocturnal pain wakes the patient up at night (usually at the same time )
Usually a patient has a glass of milk by their beside to relieve pain which works directly even at the beginning of drinking
d. duration is different
e. Irradiation to the back, or right upper quadrant sometimes no irradiation present .
The pain is burning or corrosive
Pain is relieved by food intake , antacids, Belladonna preparations ,by heat application, by vomiting due to antiperistaltics ,
- Gastric dyspepsia
Shown by -vomiting at the highest point of the pain, leads to pain relief
-Belching by air or acid
3- heartburn i .e pain-heartburn may be pain equivalent
4.Gut dyspepsia
Usually present in exacerbation, spastic gut dyskinesia, dense fry fragmented stools like stools of sheep
5.Astenoneurotic
6.local changes
Results of physical examination for peptic ulcer disease
1.Palpation
Superficial palpitation of the abdomen reveals local painful ness in the left(for mediagastric ulcers )or right(pyloric or duodenal ulcers) or directly below xyphoid process(localisation in upper stomach
- painful palpation combines with enhanced resistance or rigidity of muscles of the anterior abdominal wall
Depending on ulcer localisation, palpation reveals painful ness in the pyloric and pyloroduodenal ventral points in the points of
- Herbst
- Openkovsky
- Boas
- Pevzener
- Herbst
T5-7th spinous process
For ulcer in upper parts of stomach - Openkovsky
78-L2
For ulcer in the body or pylorus and duodenal bulb
3.Boas
T10-12 transverse processes
On the left for ulcer in the stomach body , on the right for ulcer in pylorus or duodenal bulb
4.Pevzener
Ulcer of posterior wall
On bisector of the angle formed by the spine and right 12th rib
During percussion
1.Mendels method
To detect painful ness or tenderness of abdominal wall
Pain causes by exaggerated sensitive of parietal leaf in the place of the projected organ
- Shchetkin-Blumberg sign
- Vasilenkos sign
Lab-instrumental diagnosis of peptic ulcer disease
- CBC-anemia (iron deficiency)
- Stool for gregersin reaction
- ph metry
- X-ray with barium contrast
- FGS
- Microbiological
- Hystological
- immunological
Specific diagnosis of H.pylori infections
1:Microbiological
2:Morphological with hematoxylin staining and eosin , also Gram stain , Romanowsky-Giemsaetc
Choice of stain depends on method of investigation
3:Biochemical
Based on ability of h.pylori to convert urea to ammonia
4. Immunologic
Identifying specific antibodies to h.pylori
IgA, G, M using ELISA
