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DISEASE
(PUD)
Definition:
ØAn excavation (hollowed-out area) that forms
in the mucosal wall of the stomach, in the
pylorus (the opening the stomach and
duodenum), in the duodenum (the first part of
small intestine), or in the esophagus. Erosion of
a circumscribed area of mucous membrane is
the cause. This Erosion may extend as deeply as
the muscle layers or through the muscle to the
peritoneum.
Classifications:
ØStomach (called gastric ulcer)
Types:
Ø
ØType I: Ulcer along the lesser curve of stomach
ØType II: Two ulcers present - one gastric, one duodenal
ØType III: Prepyloric ulcer
ØType IV: Proximal gastro esophageal ulcer
ØType V: Anywhere along gastric body, NSAID induced
Ø
Causes:
ØHelicobacter Pylori
ØNonsteroidal Anti-inflammatory Drug (NSAID)
ØTobacco Smoking
ØStress
ØCaffeine
Helicobacter Pylori:
A major causative factor (60% of gastric and up to 90% of
duodenal ulcers) is chronic inflammation due to
Helicobacter pylori that colonizes the antral mucosa. The
immune system is unable to clear the infection, despite the
appearance of antibodies. Thus, the bacterium can cause a
chronic active gastritis (type B gastritis), resulting in a
defect in the regulation of gastrin production by that part
of the stomach, and gastrin secretion can either be
decreased (most cases) resulting in hypo- or achlorhydria
or increased. Gastrin stimulates the production of gastric
acid by parietal cells and, in H. pylori colonization
responses that increase gastrin, the increase in acid can
contribute to the erosion of the mucosa and therefore ulcer
formation.
Nonsteroidal Anti Inflammatory Drug:
Another major cause is the use of NSAIDs. The gastric
mucosa protects itself from gastric acid with a layer of
mucus, the secretion of which is stimulated by certain
prostaglandins. NSAIDs block the function of
cyclooxygenase 1 (cox-1), which is essential for the
production of these prostaglandins. COX-2 selective anti-
inflammatories (such as celecoxib or the since withdrawn
rofecoxib) preferentially inhibit cox-2, which is less
essential in the gastric mucosa, and roughly halve the risk
of NSAID-related gastric ulceration. As the prevalence of H.
pylori-caused ulceration declines in the Western world due
to increased medical treatment, a greater proportion of
ulcers will be due to increasing NSAID use among
individuals with pain syndromes as well as the growth of
aging populations that develop arthritis.
Tobacco Smoking:
Tobacco smoking leads to atherosclerosis and vascular
spasms, causing vascular insufficiency and promoting the
development of ulcers through ischemia. Nicotine
contained in cigarettes can increase parasympathetic
nerve activity to the gastrointestinal tract by acting on the
nicotinic receptors at synapses - increased stimulation to
the enterochromaffin-like cells and G cells increases the
amount of histamine and gastrin secreted and therefore
increases the acidity of the gastric juice. Similarly,
glucocorticoids lead to atrophy of all epithelial tissues.
However, these factors, along with diet or spices, blood
type, and other factors suspected to cause ulcers until
late in the 20th century, are actually of relatively minor
importance in the development of peptic ulcers.
Stress:
Researchers also continue to look at stress as a
possible cause, or at least complication, in the
development of ulcers. There is debate as to whether
psychological stress can influence the development of
peptic ulcers. Burns and head trauma, however, can
lead to physiologic stress ulcers, which are reported
in many patients who are on mechanical ventilation.
Caffeine:
Ø
Caffeine seems to stimulate acid secretion in
the stomach, which can aggravate the pain of
an existing ulcer. However, the stimulation of
stomach acid cannot be attributed solely to
caffeine.
Ø
Signs & Symptoms:
Øabdominal pain, classically epigastric with severity relating to
mealtimes, after around 3 hours of taking a meal (duodenal ulcers are
classically relieved by food, while gastric ulcers are exacerbated by
it);
ØHelicobacter Pylori
Ø
ØUse of Nonsteroidal Anti-Inflammatory Drug (NSAIDs)
Ø
ØAlcohol
Ø
ØTobacco Smoking
Ø
ØCirrhosis
Ø
ØStress
Ø
ØGastritis
Different Laboratory and Diagnostic Procedures
An esophagogastroduodenoscopy (EGD), a form of endoscopy, also
known as a gastroscopy, is carried out on patients in whom a peptic
ulcer is suspected. By direct visual identification, the location and
severity of an ulcer can be described.
ØDirect 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;
Microscopic appearance
A gastric peptic ulcer is a mucosal defect which penetrates the
muscularis mucosae and muscularis propria, produced by acid-pepsin
aggression. Ulcer margins are perpendicular and present chronic
gastritis. During the active phase, the base of the ulcer shows 4
zones: inflammatory exudate, fibrinoid necrosis, granulation tissue
and fibrous tissue. The fibrous base of the ulcer may contain vessels
with thickened wall or with thrombosis.
Differential diagnosis of epigastric pain
ØHepatic congestion
ØCholecystitis
Pathophysiology:
with alcohol
Acid andabuse,
pepsinogen
smoking,
release
use of
with
aspirin
chronic
and vagal
NSAIDsInfection
response to
with
increased
Helicobacter
stressPylori
Low of mucosal cells; Low quality of mucous; Less of tight juntion between cells
Infection gives increased gastrin and decreased somatostation production
Severe Ulcerations: