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Peptic Ulcer Disease

Peptic Ulcer Disease

Gastrointestinal System

Peptic ulcer disease is characterised by a burning epigastric pain, caused by a break in the mucosal lining of the stomach and/or duodenum. The break in the mucosal surface is more than 5 mm in size, with depth to the submucosa.

Gastroduodenal Mucosal Defense

The gastric mucosa is under a constant attack by a host of noxious agents (acid, pepsin, bile salts, pancreatic enzymes, drugs and bacterias). However, it is protected by a three-level barrier composed of pre-epithelial, epithelial and sub-epithelial elements.

  • Pre-epithelial : Mucus, Bicarbonate, Surface active phospholipids.

  • Epithelial : Cellular resistance, Restitution, Growth factors, Prostaglandins, Cell proliferation.

  • Sub-epithelial : Blood flow, Leukocytes.

Etiology

  • H. pylori infection (accounts for the majority of cases).

  • NSAIDs.

  • Cigarette smoking

  • Genetic predisposition.

  • Psychological stress.

  • Dietary habit (eg. Consumption of beverages containing alcohol and caffeine).

  • Specific chronic disorders :

    • Systemic mastocytosis.
    • Chronic pulmonary disease.
    • Chronic renal failure.
    • Cirrhosis.
    • Nephrolithiasis.
    • Alpha-antitrypsin deficiency.

Clinical Features

History

  • Epigastric pain described as a burning or gnawing discomfort.

    • Duodenal Ulcer : Pain typically occurs 90 minutes to 3 hours after a meal and is frequently relieved by antacids or food.
    • Gastric Ulcer : Pain is precipitated by food, with nausea and vomiting being more common.

  • Variation in the abdominal pain and associated symptoms may indicate ulcer complication :

    • Penetrating ulcer (pancreas) : Constant dyspepsia, not relieved by food or antacids or radiates to the back.
    • Perforation : Sudden onset of severe generalised abdominal pain.
    • Gastric outlet obstruction : Pain worsening with meals, nausea and vomiting of undigested food.
    • Gastrointestinal Bleeding : Tarry stools or coffee ground emesis.

Physical Examination

  • Epigastric tenderness is the most common finding.
  • Dehydration (Secondary to vomiting or active g.i. blood loss) : Tachycardia and orthostasis.
  • Perforation : Severely tender, board-like abdomen.
  • Gastric outlet obstruction : Presence of succussion splash, indicating retained fluid in stomach.

Diagnostic Evaluation

Radiography (Barium study)

  • Duodenal ulcer : Appears as a well-documented crater, most often seen in the bulb.
  • Benign gastric ulcer : Appears as a discrete crater with radiating mucosal folds originating from the ulcer margins.
  • Malignant gastric ulcer : Ulcers appears greater than 3 cm in size or associated with a mass.

Endoscopy

  • Allows direct visualisation of the mucosa, photographic documentation of mucosal defect and tissue biopsy.
  • Most sensitive and specific method to examine upper gastrointestinal tract.

Test for detection of H. pylori

  • Invasive (Biopsy required) : Rapid urease, Histology, Culture.
  • Non-invasive : Serology, Urease breath test, Stool antigen.

Complications

Gastro-intestinal bleeding

  • Most common complication (around 15%).
  • Higher incidence in elderly due to increased use of NSAIDs.

Perforation

  • Second most common complication (6-7%).
  • The contents of stomach escape into the peritoneal cavity leading to peritonitis.

Penetration

  • Form of perforation, in which the ulcer bed tunnels into an adjacent organ.
  • Duodenal ulcers : Tends to penetrate posteriorly into the pancreas, leading to pancreatitis.
  • Gastric ulcers : Tend to penetrate into the left hepatic lobe.

Gastric outlet obstruction

  • Least common complication (1-2%).
  • Cardinal signs : Nausea, vomiting, abdominal distention.
  • May occur secondary to ulcer-related inflammation and edema or a fixed, mechanical obstruction due to scar formation, in the peri-pyloric region.

Management

General Measures

  • Avoid cigarette smoking and use of NSAIDs.
  • Alcohol in moderation is not harmful and no special dietary advice is required.

Medications

  • Drugs that inhibit acid secretion :

    • H2 antagonists : Ranitidine (150mg BD).
    • Proton pump inhibitors : Pantoprazole (40mg OD), Rabeprazole (20mg OD).

  • Drugs that enhance mucosal defense and prokinetic agents :

    • Colloidal bismuth (125mg 6 hourly).
    • Misoprostol (200mg 6 hourly).
    • Sucralfate (2g BD).
    • Domperidone (10-20mg TDS).

Surgical Treatment

  • Emergency surgery is indicated in case of perforation and haemorrhage while elective surgery is indicated when there are complications such as gastric outflow obstruction and recurrent ulcer following gastric surgery.

  • In emergency situation, under-running the ulcer for bleeding or oversewing (patch repair) for perforation is recommended.

  • The treatment of choice for chronic non-healing gastric ulcer is partial gastrectomy, preferably with a Billroth I anastomosis.

  • Complications of gastric resection or vagotomy :

    • Early satiety and vomiting.
    • Bile reflux gastritis.
    • Late Dumping Syndrome.
    • Diarrhoea and maldigestion.
    • Weight loss.
    • Anemia.
    • Metabolic bone disease.
    • Gastric cancer.

Points to Note

  • Restitution : Restoration of a damaged region by migration of gastric epithelial cells bordering the site of injury.

  • Role of Prostaglandins :

    • Regulates release of mucosal bicarbonate and mucus.
    • Maintains the blood flow of the gastric mucosa and epithelial cell restitution.

  • Cigarette smoking appears to decrease healing rate, impair response to therapy and increase ulcer related complications.

  • Succussion splash (Gastric splash) : Sloshing sound, heard during sudden movement of the patient on abdominal auscultation. It reflects the presence of gas and fluid in an obstructed organ, as in gastric outlet obstruction.

  • A large number of patients suggestive of ulcer have non-ulcer dyspepsia, hence, in healthy individuals with age less than 45 years, empirical therapy is recommended before starting any diagnostic evaluation.

  • Radiographic studies that shows a gastric ulcer must be followed by endoscopy and biopsy, since gastric ulcers (around 8%) that appear benign by appearance are found malignant on endoscopy and biopsy.

  • Billroth I anastomosis : The ulcer and ulcer-bearing area of the stomach are resected.

References

  • Harrison's Principles of Internal Medicine (17th edition), Fauci, Braunwald, Jasper, Hauser, Longo, Jameson, Loscalzo, The McGraw-Hill Companies.

  • The image used in the cover is licensed under the Creative Commons Attribution-Share Alike 4.0 International license.

    • Description : Gastric Ulcer.
    • Source : Own work.
    • Author : BruceBlaus.

*This article is an excerpt from the above mentioned book and Medical Sutras does not make any ownership or affiliation claims.