Peptic Ulcer; Types, Causes, Symptoms, Diagnosis, Treatment

Peptic Ulcer








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Peptic ulcer (stomach or duodenal) is a break in the inner lining of the esophagus, stomach, or duodenum. A peptic ulcer of the stomach is called a gastric ulcer; of the duodenum, a duodenal ulcer; and of the esophagus, an esophageal ulcer. Peptic ulcers occur when the lining these organs is eroded by the acidic digestive (peptic) juices that the cells of the lining secrete of the stomach secrete. A peptic ulcer differs from an erosion because it extends deeper into the lining and incites more of an inflammatory reaction from the tissues that are involved, occasionally with scaring. Peptic ulcer also is referred to as peptic ulcer disease.

Types of Peptic Ulcer 

There are three types of peptic ulcers:

  • Gastric ulcers: ulcers that develop inside the stomach
  • Esophageal ulcers: ulcers that develop inside the esophagus
  • Duodenal ulcers: ulcers that develop in the upper section of the small intestines, called the duodenum

By Names

1. Esophagus
2. Stomach
3.Ulcers
4.Duodenum
5.Mucosa
6.Submucosa
7.Muscle

By location

  • Duodenum (called duodenal ulcer)
  • Esophagus (called esophageal ulcer)
  • Stomach (called gastric ulcer)
  • Meckel’s diverticulum (called Meckel’s diverticulum ulcer; is very tender with palpation)

Modified Johnson

  • Type I: Ulcer along the body of the stomach, most often along the lesser curve at incisura angularis along the locus minoris resistantiae. Not associated with acid hypersecretion.
  • Type II: Ulcer in the body in combination with duodenal ulcers. Associated with acid oversecretion.
  • Type III: In the pyloric channel within 3 cm of pylorus. Associated with acid oversecretion.
  • Type IV: Proximal gastroesophageal ulcer
  • Type V: Can occur throughout the stomach. Associated with the chronic use of NSAIDs (such as ibuprofen).

Causes of Peptic Ulcer 

Common causes include

  • A bacterium – Helicobacter pylori bacteria commonly live in the mucous layer that covers and protects tissues that line the stomach and small intestine. Often, the H. pylori bacterium causes no problems, but it can cause inflammation of the stomach’s inner layer, producing an ulcer.
  • Regular use of certain pain relievers – Taking aspirin, as well as certain over-the-counter and prescription pain medications called nonsteroidal anti-inflammatory drugs (NSAIDs) can irritate or inflame the lining of your stomach and small intestine. These medications include ibuprofen  and naproxen sodium, but not acetaminophen .
  • Peptic ulcers are more common in older adults who take these pain medications frequently or in people who take these medications for osteoarthritis.
  • The food is partially digested in the stomach and then moves on to the duodenum to continue the process.
  • Peptic ulcers occur when the acid and enzyme overcome the defense mechanisms of the gastrointestinal tract and erode the mucosal wall.

Some types of medical therapy can contribute to ulcer formation. The following factors can weaken the protective mucosal barrier of the stomach increasing the chances of getting an ulcer and slow the healing of existing ulcers.

Radiation therapy – used for diseases such as cancer – Not everyone who gets an ulcer is infected with H pylori. Aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) can cause ulcers if taken regularly.

In the past it was thought that ulcers were caused by lifestyle factors such as eating habits, cigarette smoking, and stress.

  • Elderly people with conditions such as arthritis are especially vulnerable.
  • People who have had prior ulcers or intestinal bleeding are at a higher-than-normal risk.
  • If a person takes these medications regularly, alternatives should be discussed with a health-care professional. This is especially true if the affected individual has an upset stomach or heartburn after taking these medications.People who take aspirin or other anti-inflammatory medications are at an increased risk even if they do not have H pylori infection.
    • The stool contaminates food or water (usually through poor personal hygiene).
    • The bacteria in the stool make their way into the digestive tracts of people who consume this food or water.
    • This is called fecal-oral transmission and is a common way for infections to spread.H pylori bacteria is spread through the stools (feces) of an infected person.
    • Many people who are exposed to the bacteria never develop ulcers.
    • People who are newly infected usually develop symptoms within a few weeks.
    • Researchers are trying to discover what is different about the people who develop ulcers.The bacteria are found in the stomach, where they are able to penetrate and damage the lining of the stomach and duodenum.It is more common in older adults, although it is thought that many people are infected in childhood and carry the bacteria throughout their lifetimes.
    • It is also more common in lower socioeconomic classes because these households tend to have more people living together, sharing bathrooms and kitchen facilities.
    • African Americans and Hispanic Americans are more likely to have the bacteria than Caucasians and Asian Americans.Infection with H pylori occurs in all ages, races, and socioeconomic classes.
  • It is important to distinguish between ulcers caused by H pylori and those caused by medications because the treatment is completely different.Ulcers can be linked with other medical conditions.
  • People who worry excessively are usually thought to have a condition called generalized anxiety disorder. This disorder has been linked with peptic ulcers.
  • A rare condition called Zollinger-Ellison syndrome causes peptic ulcers as well as tumors in the pancreas and duodenum.

Other medications – Taking certain other medications along with NSAIDs, such as steroids, anticoagulants, low-dose aspirin, selective serotonin reuptake inhibitors , alendronate  and risedronate , can greatly increase the chance of developing ulcers.

Research done in the 1980s showed that some ulcers are caused by infection with a bacterium named Helicobacter pylori, usually called H pylori.

Symptoms of Peptic Ulcer 

A history of heartburn, gastroesophageal reflux disease (GERD) and use of certain forms of medication can raise the suspicion for peptic ulcer. Medicines associated with peptic ulcer include NSAIDs (non-steroid anti-inflammatory drugs) that inhibit cyclooxygenase, and most glucocorticoids (e.g. dexamethasone and prednisolone).

Diagnosis of Peptic Ulcer 

The diagnosis of Helicobacter pylori can be made by:

  • Urea breath test (noninvasive and does not require EGD);
  • Direct culture from an EGD biopsy specimen; this is difficult to do, and can be expensive. Most labs are not set up to perform H. pylori cultures;
  • Direct detection of urease activity in a biopsy specimen by rapid urease test;
  • Measurement of antibody levels in the blood (does not require EGD). It is still somewhat controversial whether a positive antibody without EGD is enough to warrant eradication therapy;
  • Stool antigen test;
  • Histological examination and staining of an EGD biopsy.
  • Upper gastrointestinal series – Sometimes called a barium swallow, this series of X-rays of your upper digestive system creates images of your esophagus, stomach and small intestine. During the X-ray, you swallow a white liquid (containing barium) that coats your digestive tract and makes an ulcer more visible.
  • Laboratory tests for H. pylori – Your doctor may recommend tests to determine whether the bacterium H. pylori is present in your body. He or she may look for H. pylori using a blood, stool or breath test. The breath test is the most accurate. Blood tests are generally inaccurate and should not be routinely used.
  • Barium swallow – You drink a thick white liquid (barium) that coats your upper gastrointestinal tract and helps your doctor see your stomach and small intestine on X-rays.
  • Endoscopy (EGD) – A thin, lighted tube is inserted through your mouth and into the stomach and the first part of the small intestine. This test is used to look for ulcers, bleeding, and any tissue that looks abnormal.
  • Endoscopic biopsy – A piece of stomach tissue is removed so it can be analyzed in a lab.

If your doctor detects an ulcer, small tissue samples (biopsy) may be removed for examination in a lab. A biopsy can also identify whether H. pylori is in your stomach lining.

Differential diagnosis of Peptic Ulcer 

Conditions that may appear similar include

Treatment of Peptic Ulcer 

The type of treatment usually depends on what caused the peptic ulcer. Treatment will focus on either lowering stomach acid levels so that the ulcer can heal, or eradicating the H. pylori infection.

Medications

There are several medications that can be used to treat . They include:

  • H. pylori infection treatment-

Patients infected with H. pylori will usually need PPIs and antibiotics. This treatment is effective in most patients, and the ulcer will start to disappear within days. When treatment is over, the individual will have to be tested again to make sure the H. pylori have gone. If necessary, they will undergo another course of different antibiotics.

  • Non-steroidal anti-inflammatory drugs

    If the ulcer comes from NSAIDs, the patient will have to stop taking them. Alternatives include acetaminophen. If the person cannot stop taking NSAIDs, the doctor may minimize the dosage and review the patient’s need for them later. Another medication may be prescribed long term, alongside the NSAID.

  • Over-the-counter acid buffers — Buffers neutralize acid. They include Mylanta, Maalox, Tums, Rolaids, and Gaviscon. The liquid forms of these medications work faster But the tablets may be more convenient.Antacids that contain magnesium can cause diarrhea. And antacids that contain aluminum can cause constipation. Your doctor may advise you to alternate antacids to avoid these problems. These medicines work for a short time and they do not heal the inflammation of the esophagus.
  • Over-the-counter proton pump inhibitors  Proton pump inhibitors shut off the stomach’s acid production.Proton pump inhibitors are very effective. They can be especially helpful in patients who do not respond to H2 blockers and antacids. These drugs are more potent acid-blockers than are H2 blockers, but they take longer to begin their effect.
  • Proton pump inhibitors – should not be combined with an H2 blocker. The H2 blocker can prevent the proton pump inhibitor from working.These are prescribed at higher doses than those available in over-the-counter forms.
  • Motility drugs – These medications may help to decrease esophageal reflux. But they are not usually used as the only treatment for peptic ulcers .They help the stomach to empty faster, which decreases the amount of time during which reflux can occur.
  • Mucosal protectors – These medications coat, soothe and protect the irritated esophageal lining. One example is sucralfate (Carafate).

Over-the-counter and prescription medicines of  Peptic Ulcer 

You can buy many peptic ulcers medicines without a prescription. However, if you have symptoms that will not go away, you should see your doctor.

Antacids – Doctors often first recommend antacids to relieve heartburn and other mild   peptic ulcers. Antacids include over-the-counter medicines such as. Antacids can have side effects, including diarrhea and constipation.

H2 blockers – H2 blockers decrease acid production. They provide short-term or on-demand relief for many people with peptic ulcers. They can also help heal the esophagus, although not as well as other medicines. You can buy H2 blockers over-the-counter or your doctor can prescribe one. Types of H2 blockers include

Proton pump inhibitors (PPIs) – PPIs lower the amount of acid your stomach makes. PPIs are better at treating  peptic ulcers than H2 blockers. They can heal the esophageal lining in most people with peptic ulcers. Doctors often prescribe PPIs for long-term  peptic ulcers treatment. Such as

Talk with your doctor about taking lower-strength omeprazole or lansoprazole, sold over the counter.

Antibiotics – Antibiotics, including erythromycin , can help your stomach empty faster. Erythromycin has fewer side effects than prokinetics; however, it can cause diarrhea.

Prokinetics – Prokinetics help your stomach empty faster. Prescription prokinetics include

  • bethanechol 
  • metoclopramide 

Both of these medicines have side effects, including

Prokinetics can cause problems if you mix them with other medicines, so tell your doctor about all the medicines you’re taking.

Prevention of Peptic Ulcer 

There are a lot of things you can do to prevent the symptoms of GERD. Some simple lifestyle changes include

  • Elevate the head of your bed at least six inches. If possible, put wooden blocks under the legs at the head of the bed. Or, use a solid foam wedge under the head portion of the mattress. Simply using extra pillows may not help.
  • Avoid foods that cause the esophageal sphincter to relax during their digestion. These include:
    • Coffee
    • Chocolate
    • Fatty foods
    • Whole milk
    • Peppermint
    • Spearmint
  • Limit acidic foods that make the irritation worse when they are regurgitated. These include citrus fruits and tomatoes.
  • Excess pounds put pressure on your abdomen, pushing up your stomach and causing acid to reflux into your esophagus.
  • Smoking decreases the lower esophageal sphincter’s ability to function properly.
  • If you regularly experience heartburn while trying to sleep, place wood or cement blocks under the feet of your bed so that the head end is raised by 6 to 9 inches. If you can’t elevate your bed, you can insert a wedge between your mattress and box spring to elevate your body from the waist up. Raising your head with additional pillows isn’t effective.
  • Wait at least three hours after eating before lying down or going to bed.
  • Put down your fork after every bite and pick it up again once you have chewed and swallowed that bite.
  • Common triggers include fatty or fried foods, tomato sauce, alcohol, chocolate, mint, garlic, onion, and caffeine.
  • Clothes that fit tightly around your waist put pressure on your abdomen and the lower esophageal sphincter.
  • Avoid carbonated beverages. Burps of gas force the esophageal sphincter to open and can promote reflux.
  • Eat smaller, more frequent meals.
  • Do not eat during the three to four hours before you go to bed.
  • Avoid drinking alcohol. It loosens the esophageal sphincter.
  • Lose weight if you are obese. Obesity can make it harder for the esophageal sphincter to stay closed.
  • Avoid wearing tight-fitting garments. Increased pressure on the abdomen can open the esophageal sphincter.
  • Use lozenges or gum to keep producing saliva.
  • Do not lie down after eating.

Complications of Peptic Ulcer 

  • Perforation – A hole develops in the lining of the stomach or small intestine and causes an infection. A sign of a perforated ulcer is sudden, severe abdominal pain.
  • Internal bleeding – Bleeding ulcers can result in significant blood loss and thus require hospitalization. Signs of a bleeding ulcer include lightheadedness, dizziness, and black stools.
  • Scar tissue This is thick tissue that develops after an injury. This tissue makes it difficult for food to pass through your digestive tract. Signs of scar tissue include vomiting and weight loss.
  • Gastrointestinal bleeding is the most common complication. Sudden large bleeding can be life-threatening. It occurs when the ulcer erodes one of the blood vessels, such as the gastroduodenal artery.
  • Perforation (a hole in the wall of the gastrointestinal tract) often leads to catastrophic consequences if left untreated. Erosion of the gastro-intestinal wall by the ulcer leads to spillage of the stomach or intestinal content into the abdominal cavity. Perforation at the anterior surface of the stomach leads to acute peritonitis, initially chemical and later bacterial peritonitis. The first sign is often sudden intense abdominal pain; an example is Valentino’s syndrome, named after the silent-film actor who experienced this pain before his death. Posterior wall perforation leads to bleeding due to the involvement of gastroduodenal artery that lies posterior to the first part of the duodenum.
  • Penetration is a form of perforation in which the hole leads to and the ulcer continues into adjacent organs such as the liver and pancreas.
  • Gastric outlet obstruction is a narrowing of the pyloric canal by scarring and swelling of the gastric antrum and duodenum due to peptic ulcers. The person often presents with severe vomiting without bile.
  • Cancer is included in the differential diagnosis (elucidated by biopsy), Helicobacter pylori as the etiological factor making it 3 to 6 times more likely to develop stomach cancer from the ulcer.

References

 

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