Brief Summary of Peptic ulcers

General Medicine Add comments

Jul212011

Peptic ulcer is a disruption in the gastric or duodenal mucosa when normal defense mechanisms are
overwhelmed or impaired by acid or pepsin. Ulcers are circumscribed lesions that extend through
the muscularis mucosa. Ulcers are five times more common on the duodenum.
Causes
Researchers recognize three major causes of peptic ulcer disease: infection with Helicobacter pylori,
use of nonsteroidal anti-inflammatory drugs (NSAIDs), and pathologic hypersecretory states such as
Zollinger-Ellison syndrome.
H. pylori is the cause of the majority of duodenal and gastric ulcers. Following treatment with
standard therapies, 70% to 85% of patients have a documented recurrence (by endoscopy) within 1
year.
Other causes include the use of certain drugs, such as salicylates and other NSAIDs, which
encourage ulcer formation by inhibiting the secretion of prostaglandins (the substances that
suppress ulceration). Certain illnesses such as pancreatitis, hepatic disease, Crohns disease,
Zollinger-Ellison syndrome, and preexisting gastritis are also known causes. Additionally, having
a type A personality increases autonomic nervous system effects on the gastric mucosa.
Predisposing factors
Ulcers are more common in smokers and those who regularly use NSAIDs. (Smoking increases the
amount of hydrochloric acid in the stomach; nicotine reduces the bicarbonate content of pancreatic
secretions and also decreases the degree of acid neutralization.) Diet and alcohol dont appear to
contribute to the development of peptic ulcer disease. Its unclear whether emotional stress is a
contributing factor.
Signs and symptoms
Symptoms vary with the type of ulcer.
Gastric ulcers
Gastric ulcers are usually signaled by pain that becomes more intense with eating. The pain is
usually constant because the gastric mucosa is sensitive to acid secretion. Nausea or anorexia may
occur.
Duodenal ulcers
Duodenal ulcers produce epigastric pain thats gnawing, dull, aching, or hunger-like. The pain
is relieved by food or antacids and typically recurs 2 to 4 hours later. Weight loss or vomiting is
typically a sign of malignancy or gastric outlet obstruction.
Well-localized midepigastric pain (relieved by food), weight gain (because the patient eats to relieve
discomfort), and a peculiar sensation of hot water bubbling in the back of the throat are other
reported signs.
Exacerbations tend to recur several times a year, then fade into remission. Vomiting and other
digestive disturbances are rare.
Complications
Both kinds of ulcers may be asymptomatic or may penetrate the pancreas and cause severe back
pain. Other complications of peptic ulcers include perforation, hemorrhage, and pyloric obstruction.
Diagnosis
A patient with dyspepsia may have an upper GI series to help diagnose a peptic ulcer. For a patient
with a confirmed gastric ulcer, an upper endoscopy should be performed to help distinguish between
benign and malignant disease. An endoscopy should also be performed in a patient with GI bleeding
to identify areas of ulceration. In a patient with a history of peptic ulcer disease, H. pylori may be
diagnosed with urease breath testing or serologic testing. H. pylori can also be diagnosed by biopsy
via upper endoscopy.
Other tests may disclose occult blood in the stools and a decreased hemoglobin level and
hematocrit from GI bleeding.
Treatment
H. pylori can be treated with a combination of agents and eradicated with antibiotics. Pharmacologic
treatments include antisecretory agents, such as proton pump inhibitors and histamine-2 (H2)-
receptor antagonists. Proton pump inhibitors work by binding to hydrogen-potassium adenosine
triphosphatase, located at the surface of gastric parital cells to block formation of gastic acid. H2-
receptor antagonists inhibit histamine binding to H2 receptors on the gastric parietal cell, which in
turn decreases acid secretion. Drug therapy, which protects the mucosa, includes prostaglandin
analogs and antacids. Prostaglandin analogs may be given to patients taking NSAIDs to suppress
ulceration.
GI bleeding may be treated by giving H2-receptor antagonists I.V. as a continuous infusion. Upper
endoscopy is preferred as a diagnostic tool when GI bleeding is present because an injection of
epinephrine or saline (to surround the ulcer) can be performed to stop the bleeding during the
procedure; cautery may also be used for hemostasis.
Surgery is indicated for perforation of the ulcer, continued bleeding despite medical treatment, and
suspected malignancy. Surgical procedures for peptic ulcers and gastric outlet obstruction include:
vagotomy and pyloroplasty: severing one or more branches of the vagus nerve to reduce
hydrochloric acid secretion and refashioning the pylorus to create a larger lumen and facilitate
gastric emptying
distal subtotal gastrectomy (with or without vagotomy): excising the antrum of the stomach,
thereby removing the hormonal stimulus of the parietal cells, followed by anastomosis of the
remainder of the stomach to the duodenum or the jejunum.