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Peptic Ulcer

Ulcer Disease

Peptic ulcer is a common defect in the gastric or duodenal mucosa which may be caused by a variety of factors.


Presentation

In uncomplicated cases of peptic ulcer disease, the clinical findings are few and non-specific with the following often recorded:

  • Succussion splash as a result of partial or complete gastric outlet obstruction
  • Mild epigastric tenderness 
  • Right upper quadrant tenderness which may suggest a biliary etiolog
  • Guaiac-positive stool as a result of occult blood loss
  • Melena as a result of acute or subacute gastrointestinal bleeding

In patients with perforated peptic ulcer disease, onset of severe, sharp, abdominal pain is a common presentation [7]. In some other patients, generalised pain is described while epigastric pain is seen in rare cases. Since slight movement can bring about worsening of pains, a common presentation among peptic ulcer patients is the assumption of fetal position most of the time.

Abdominal examination also shows general tenderness, rigidity, rebound tenderness and guarding.

Non-Cardiac Chest Pain
  • Other PUD symptoms include the following: Heartburn (acid reflux) Indigestion (dyspepsia) Nausea and vomiting Non-cardiac chest pain Weight loss In patients who have peptic ulcer disease, stress, diet (e.g., spicy foods, foods that are high in fat), alcohol[healthcommunities.com]
Anemia
  • A blood test for anemia may be done, and a stool sample may be checked for the presence of blood. Both of these tests can indicate a bleeding ulcer.[health.harvard.edu]
  • Bloody or dark tarry stools Chest pain Fatigue Vomiting, possibly bloody Weight loss Diagnosis To diagnose an ulcer, your doctor may order: An upper endoscopy (EGD) An upper GI series of X-ray tests for H. pylori A hemoglobin blood test to check for anemia[wexnermedical.osu.edu]
Abdominal Pain
  • We report a case of an elderly woman who presented with severe abdominal pain and positive rebound sign, in whom abdominal sonography demonstrated indirect signs of PUP, the site of perforation, and active air fluid leakage through the perforated anterior[ncbi.nlm.nih.gov]
  • A 42-year-old man with a 10-year history of HLA-B27-positive ankylosing spondylitis presented with upper abdominal pain and nausea after receiving oral ketoprofen 200 mg/day.[ncbi.nlm.nih.gov]
  • Plain radiograph Abdominal films have little role in the setting of vague/chronic upper abdominal pain, and have a very low yield.[radiopaedia.org]
  • In patients with peptic ulcer the most common symptom is abdominal pain.[symptoma.com]
Loss of Appetite
  • Less common symptoms include: belching a bloated feeling nausea, vomiting loss of appetite With a duodenal ulcer, nausea, vomiting, or pain that is worsened by eating usually indicate swelling or obstruction of the narrow channel that connects the stomach[health.harvard.edu]
  • Symptoms Symptoms include: Upper abdominal pain Pain on hunger Pain at night Pain relieved by food Nausea, loss of appetite, fullness after eating can occur.[singhealth.com.sg]
  • Symptoms may include: burning pain in the stomach nausea vomiting chest pain loss of appetite weight loss difficulty feeding blood in the stools or vomit (may be red or black) unger pain a few hours after eating (pain often goes away after eating something[virtualpediatrichospital.org]
  • […] of appetite Weight loss Bloating Nausea, vomiting Symptoms that require immediate medical attention include sharp, sudden, persistent stomach pain, bloody or black (tarry) stools, or bloody vomit or vomit that looks like coffee grounds.[labtestsonline.org]
Dyspepsia
  • Patients with dyspepsia were selected and divided into three groups of non-ulcer dyspepsia (NUD, n 22), peptic ulcer disease (PUD, n 25), and gastric cancer (GC, n 27) according to their endoscopic and histopathological examinations.[ncbi.nlm.nih.gov]
  • Serum VacA antibody was associated with increased risk of PUD compared with gastritis/functional dyspepsia (FD) (OR 1.96, 95%CI 1.56-2.46, P 0.001).[ncbi.nlm.nih.gov]
  • However, the link between molecular H2 and the pathogenesis of peptic-ulcer disease (PUD) and non-ulcerous dyspepsia (NUD) by the enzymatic activity of H. pylori still remains mostly unknown.[ncbi.nlm.nih.gov]
  • The gene expression levels of these molecules were compared in three groups of non-ulcer dyspepsia (NUD) as a control group (n 52); peptic ulcer disease (PUD), (n 53); and gastric cancer (GC), (n 39).[ncbi.nlm.nih.gov]
  • Updated 09/21/2018 Category: Diet A diet that avoids stomach irritants is for those patients who suffer from symptoms of peptic ulcer disease or non-ulcer dyspepsia.[gicare.com]
Black Stools
  • When symptoms occur, they include: A gnawing or burning pain in the middle or upper stomach between meals or at night Bloating Heartburn Nausea or vomiting In severe cases, symptoms can include: Dark or black stool (due to bleeding) Vomiting Weight loss[my.clevelandclinic.org]
  • Symptoms that require immediate medical attention include sharp, sudden, persistent stomach pain, bloody or black stools, or bloody vomit or vomit that looks like coffee grounds.[labtestsonline.org.au]
  • Complications of Peptic Ulcers Bleeding can occur from ulcers causing black stool (the appearance of blood after undergoing digestion) or even vomiting of blood.[singhealth.com.sg]
  • Other patients have no pain but have black stools, indicating that the ulcer is bleeding. Bleeding is a very serious complication of ulcers. Diagnosis A diagnosis of peptic ulcers can be suspected from the patient’s medical history.[gicare.com]
Melena
  • Of all patients admitted for endoscopy, 147/649 (23%) had PUD with the main symptom of melena. Of these PUD patients, 35% had major stigmata of bleeding (Forrest Ia-IIb) in endoscopy.[ncbi.nlm.nih.gov]
  • hematochezia (20%) hematemesis (30%) both melena and hematemesis (50%) perforation affects up to 6% of ulcer patients 1 generalised acute abdominal pain, peritonism and shock 2 pain may radiate to the right shoulder and back 2 pain may prominently[radiopaedia.org]
  • Melena – black very sticky stool, often compared to roof tar. This is a common symptom of a bleeding ulcer. Black stool that looks like melena can be caused by taking iron medications and by drugs like Pepto-Bismol .[patients.gi.org]
  • […] following often recorded: Succussion splash as a result of partial or complete gastric outlet obstruction Mild epigastric tenderness Right upper quadrant tenderness which may suggest a biliary etiolog Guaiac-positive stool as a result of occult blood loss Melena[symptoma.com]
Halitosis
  • His symptoms disappeared after two weeks, but he took antibiotics to kill the remaining bacteria at the urging of his wife, since halitosis is one of the symptoms of infection. [37] This experiment was published in 1984 in the Australian Medical Journal[en.wikipedia.org]
Chest Pain
  • Other PUD symptoms include the following: Heartburn (acid reflux) Indigestion (dyspepsia) Nausea and vomiting Non-cardiac chest pain Weight loss In patients who have peptic ulcer disease, stress, diet (e.g., spicy foods, foods that are high in fat), alcohol[healthcommunities.com]
  • The pain: Starts between meals or during the night Briefly stops if you eat or take antacids Lasts for minutes to hours Comes and goes for several days or weeks Other possible symptoms include: Bloody or dark tarry stools Chest pain Fatigue Vomiting,[wexnermedical.osu.edu]
  • Symptoms of an ulcer can include a burning pain in the stomach, chest pain, vomiting, or blood in the stools or vomit. The bacteria that can cause peptic ulcers are contagious. Peptic ulcers are most often treated with antibiotics.[virtualpediatrichospital.org]
  • Other common signs of a peptic ulcer include: changes in appetite nausea bloody or dark stools unexplained weight loss indigestion vomiting chest pain Two types of tests are available to diagnose a peptic ulcer.[healthline.com]

Workup

In diagnosis of ulcers, patients are subjected to diagnostic tests such as:

  • Tests for Helicobacter pylori (stool, blood or breath depending on condition)
  • Endoscopy (biopsy used in identification of Helicobacter pylori in the stomach lining)
  • X-ray of the upper digestive system 
Helicobacter Pylori
  • Its impact is seen in 'idiopathic' and Helicobacter pylori-associated ulcers, and in acute surgical cases.[ncbi.nlm.nih.gov]
  • Again, Helicobacter pylori colonisation often results in inflammation. To reduce the risk of peptic ulcer, the following is advised: Protect yourself from Helicobacter pylori infection.[symptoma.com]
  • In vitro anti-Helicobacter pylori activity was performed through disc diffusion and minimum inhibitory concentration method.[ncbi.nlm.nih.gov]
  • In Uganda, Helicobacter pylori is highly resistant to CLA and FLQ.[ncbi.nlm.nih.gov]
  • Organ transplant recipients with PUD have lower rates of Helicobacter pylori positivity compared to the general population.[ncbi.nlm.nih.gov]
Occult Blood Positive
  • blood positive test acute presentation: melena / hematochezia (20%) hematemesis (30%) both melena and hematemesis (50%) perforation affects up to 6% of ulcer patients 1 generalised acute abdominal pain, peritonism and shock 2 pain may radiate to the[radiopaedia.org]
HLA-B27
  • A 42-year-old man with a 10-year history of HLA-B27-positive ankylosing spondylitis presented with upper abdominal pain and nausea after receiving oral ketoprofen 200 mg/day.[ncbi.nlm.nih.gov]

Treatment

Treatment for peptic ulcers is dependent on the cause of the condition. Antibiotic medications taken over a period of two weeks can eradicate Helicobacter pylori [8]. Antibiotics are often used with additional medications to reduce stomach acid.

In the case of excessive acid production, protein pump inhibitors that block the production and promote healing can be used. Other treatment agents are histamine blockers, and antacids. Antacids are used to provide relief but they do not heal ulcers [9].

Prognosis

As long as the underlying cause is addressed, prognosis is positive. Majority of patients are successfully treated with eradication of Helicobacter pylori, adequate use of antisecretory therapy and the avoidance of drugs that are etiologic factors [6]. When Helicobacter pylori is eradicated, the natural history of the disease is altered and this leads to reduction of the recurrence rate from 60-90% to around 10-20%.

Mortality rate for peptic ulcer disease has decreased a great deal over the last three decades to approximately 1 death for every 100,000 cases.

Etiology

Ulcers are caused by a variety of factors but in most cases, they arise as a result of Helicobacter pylori infection [3]. Other main causes of ulcer are drug use, unfavourable life style choices, severe physiologic stress, hypersecretory states and genetics.

Other lesser etiologic factors include:

Epidemiology

Peptic ulcer affects around 4.5 million people each year in the US. In other countries, the figures are variable and incidence is determined majorly on association with the major causes of peptic ulcer [4].

In the past, peptic ulcer was seen more in males than in females but now it occurs similarly in both males and females. Age statistics show that ulcer occurrence is declining in younger men especially for duodenal ulcer, while rates continue to increase in older women.

Sex distribution
Age distribution

Pathophysiology

Peptic ulcers signify a defect in the gastric or duodenal mucosa which extends through the muscularis mucosa [5]. In a healthy individual, there is a physiologic balance between gastric acid secretion and gastroduodenal mucosal defense.

Mucosal injury and peptic ulcer set in when the balance between the aggressive factors and defensive mechanisms of the stomach become disrupted. Aggressive factors like Helicobacter pylori infection, alcohol pepsin and bile salts can alter the mucosal defense by allowing hydrogen ion diffusion and ensuing injury to the epithelial cell. Again, Helicobacter pylori colonisation often results in inflammation.

Prevention

To reduce the risk of peptic ulcer, the following is advised [10]:

  • Protect yourself from Helicobacter pylori infection. There is no definite path on how it spreads but evidence suggest that it can be transmitted from person to person and via food and water. Prevention can therefore be achieved by adequate hygiene and consistent washing of hands with soap and water and also eating properly cooked foods.
  • Exercise caution when using pain relievers as regular use only increases the risk of peptic ulcer. It is also advisable to take medications with meals at all times.

Summary

Peptic ulcer refers to the condition that arises when there is a clear breach in the mucosal lining of the stomach or the first part of the small intestine [1]. The former is known as gastric ulcer while the latter is known as duodenal ulcer. Peptic ulcers arise following the caustic effects of acid and pepsin in the lumen.

Peptic ulcer is defined histologically as a necrosis of the mucosa that leads to the production of lesions that are equal to or greater than 0.5 cm. It is also the most common ulcer of the gastrointestinal tract. The very painful nature of the condition is a result of the acidic nature of the gastrointestinal tract. Ulcers are often worsened by drugs like aspirin or ibuprofen.

Peptic ulcers occur four times more in the duodenum than in the stomach. 4% of gastric ulcers are as a result of a malignant tumor [2]. This is why biopsies are used in most cases to exclude the possibility of cancer. Duodenal ulcers are benign generally.

Patient Information

Peptic ulcers are sores that develop on the lining of the esophagus, stomach, and upper part of the small intestine. In patients with peptic ulcer the most common symptom is abdominal pain.

Ulcers that occur inside the stomach are known as gastric ulcers while those that occur in the throat and in the upper part of the small intestine are known as esophageal and duodenal ulcers respectively.

Treatment of ulcers in most cases is with the aid of antibiotics and medication to help reduce the pain and other symptoms that arise from it. Contrary to common opinion, eating spicy meals or working a stressful shift does not cause ulcer.

References

Article

  1. Chey WD, Wong BC. American College of Gastroenterology guideline on the management of Helicobacter pylori infection. Am J Gastroenterol. Aug 2007;102(8):1808-25.
  2. Javid G, Zargar SA, U-Saif R, Khan BA, Yatoo GN, Shah AH, et al. Comparison of p.o. or i.v. proton pump inhibitors on 72-h intragastric pH in bleeding peptic ulcer. J Gastroenterol Hepatol. Jul 2009;24(7):1236-43.
  3. Lai KC, Lam SK, Chu KM, Wong BC, Hui WM, Hu WH, et al. Lansoprazole for the prevention of recurrences of ulcer complications from long-term low-dose aspirin use. N Engl J Med. Jun 27 2002;346(26):2033-8.
  4. Lai KC, Lam SK, Chu KM, Hui WM, Kwok KF, Wong BC, et al. Lansoprazole reduces ulcer relapse after eradication of Helicobacter pylori in nonsteroidal anti-inflammatory drug users--a randomized trial. Aliment Pharmacol Ther. Oct 15 2003;18(8):829-36.
  5. Sung JJ, Tsoi KK, Ma TK, Yung MY, Lau JY, Chiu PW. Causes of mortality in patients with peptic ulcer bleeding: a prospective cohort study of 10,428 cases. Am J Gastroenterol. Jan 2010;105(1):84-9. 
  6. Bardhan KD, Cole DS, Hawkins BW, Franks CR. Does treatment with cimetidine extended beyond initial healing of duodenal ulcer reduce the subsequent relapse rate? Br Med J (Clin Res Ed) 1982; 284:621.
  7. Gudmand-Høyer E, Jensen KB, Krag E, et al. Prophylactic effect of cimetidine in duodenal ulcer disease. Br Med J 1978; 1:1095.
  8. Current status of maintenance therapy in peptic ulcer disease. The ACG Committee on FDA-Related Matters. Am J Gastroenterol 1988; 83:607.
  9. Jorde R, Bostad L, Burhol PG. Asymptomatic gastric ulcer: a follow-up study in patients with previous gastric ulcer disease. Lancet 1986; 1:119.
  10. Howden CW, Hunt RH. The relationship between suppression of acidity and gastric ulcer healing rates. Aliment Pharmacol Ther 1990; 4:25.

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Last updated: 2018-06-22 12:33