PEPTIC ULCER PANKAJ BHAWAR

DEFINITION AND DESCRIPTION Peptic ulcers are produced by an imbalance between the gastro- duodenal mucosal defense mechanisms and damaging forces of gastric acid and pepsin, combined with superimposed injury from environmental or immunologic agents. The mucous membrane lining the digestive tract erodes and causes a gradual breakdown of tissue. This breakdown causes a gnawing or burning pain in the upper middle part of the belly (abdomen).

As many as 80% of ulcers are associated with Helicobacter pylori, a spiral-shaped bacterium that lives in the acidic environment of the stomach. Ulcers can also be caused or worsened by drugs such as aspirin and other NSAIDs. Although H. pylori infection is usually contracted in childhood, perhaps through food, water, or close contact with an infected individual. usually doesn't cause problems in childhood, if left untreated it can cause gastritis (the irritation and inflammation of the lining of the stomach), peptic ulcer disease, and even stomach cancer later in life.

Contrary to general belief, more peptic ulcers arise in the duodenum (first part of the small intestine, just after the stomach) than in the stomach. Duodenal ulcers usually first occur between the ages of years and are twice as common in men as in women. Stomach (or gastric) ulcers usually occur in people older than 60 years and are more common in women.

Classification Stomach (called gastric ulcer) Duodenum (called duodenal ulcer) Oesophagus (called Oesophageal ulcer) Types of peptic ulcers: Type I: Ulcer along the lesser curve of stomach Type II: Two ulcers present - one gastric, one duodenal Type III: Prepyloric ulcer Type IV: Proximal gastroesophageal ulcer Type V: Anywhere

SYMPTOMS

Burning pain bloating Nausea water brash Unexplained weight loss hematemesis (vomiting of blood) Appetite changes Appetite changes Melina vomiting Blood in the stools low blood cell count (anemia) Stomach pain wakes you up at night frequent burping or hiccupping An early sense of fullness with eating

CAUSES

йHelicobacter pylori, a bacteria that is frequently found in the stomach йNonsteroidal anti-inflammatory drugs (NSAIDS) such as ibuprofen й In addition, smoking and certain other genetic and environmental factors (such as medications) may influence the course of peptic ulcer disease. йPsychological stress and dietary factors were once thought to be the cause of ulcers, although these factors are no longer thought have a major role.

Helicobacter pylori infection

¤ H. pylori is a helix-shaped ¤ Gram-negative, slow-growing organism ¤ about 3 micrometres long with a diameter of about 0.5 micrometres ¤ has 4–6 flagella ¤ Helicobacter pylori is composed of a single circular chromosome with 1,667,867 base pairs, containing about 1590 coding regions ¤ It is microaerophilic; that is, it requires oxygen, but at lower concentration than is found in the atmosphere ¤ It contains a hydrogenase which can be used to obtain energy by oxidizing molecular hydrogen (H2) that is produced by intestinal bacteria

*It produces oxidase, catalase, and urease *It is capable of forming biofilms and can convert from spiral to a possibly viable but nonculturable coccoid form, both likely to favor its survival and be factors in the epidemiology of the bacterium.

The bacterium persists in the stomach for decades in most people. Most individuals infected by H. pylori will never experience clinical symptoms despite having chronic gastritis. Approximately 10-20% of those colonized by H. pylori will ultimately develop gastric and duodenal ulcers. H. pylori infection is also associated with a 1-2% lifetime risk of stomach cancer and a less than 1% risk of gastric MALT lymphoma

Effects of smoking on PUDEffects of smoking on PUD Increased rate of gastric emptyingIncreased rate of gastric emptying Diminished pancreatic bicarbonate secretionDiminished pancreatic bicarbonate secretion Decreased duodenal pHDecreased duodenal pH Reduced mucosal blood flowReduced mucosal blood flow Inhibition of mucosal prostaglandinsInhibition of mucosal prostaglandins

NICOTINE parasympathetic nerve activity in activity in gastrointestinal tract increase stimulation to the enterochromaffin-like cells and G cells increases the amount of histamine and gastrin secreted

Gastrinomas (Zollinger Ellison syndrome), rare gastrin-secreting tumors, also cause multiple and difficult to heal ulcers. Excessive alcohol consumption Alcohol can irritate and erode the mucous lining of stomach and increases the amount of stomach acid that's produced. It's uncertain, however, whether this alone can progress into an ulcer or if it just aggravates the symptoms of an existing ulcer.

Caffeine Beverages and foods that contain caffeine can stimulate acid secretion in the stomach. This can aggravate an existing ulcer, but the stimulation of stomach acid can't be attributed solely to caffeine.

Risk Factors for Ulcers

for peptic ulcer disease : Are 50 years old or older. Diabetes may increase your risk of having H. pylori Drink alcohol excessively Smoke cigarettes or use tobacco. Have a family history of ulcer disease. for NSAID-induced ulcers : Are age 60 or older (your stomach lining becomes more fragile with age). Have had past experiences with ulcers and internal bleeding Take steroid medications, such as prednisone.

COMPLICATIONS

ж 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. Bleeding can occur as slow blood loss that leads to anemia or as severe blood loss that may require hospitalization or a blood transfusion. ж Perforation (a hole in the wall) often leads to catastrophic consequences. Erosion of the gastro- intestinal wall by the ulcer leads to spillage of 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. Posterior wall perforation leads to pancreatitis; pain in this situation often radiates to the back.

ж Penetration is when the ulcer continues into adjacent organs such as the liver and pancreas ж Scar tissue Scarring and swelling due to ulcers causes narrowing in the duodenum and gastric outlet obstruction. Patient often presents with severe vomiting. Peptic ulcers can also produce scar tissue that can obstruct passage of food through the digestive tract, causing you to become full easily, to vomit and to lose weight.

WARNING SIGNS blood in your stools losing weight pain doesn't go away With medication vomit blood sudden, severe pain vomit food eaten hours or days before ongoing nausea or repeated vomiting. feel cold or clammy feel unusually weak or dizzy

TESTS AND DIAGNOSIS CHART

Noninvasive Urea Breath Test (UBT)Blood test Invasive Biopsy Urease Test Histology

Culture Stool antigen test Upper gastrointestinal (upper GI) X-ray Other tests Endoscopy

TREATMENT

lowering the amount of acid that stomach makes, neutralizing the acid protecting the injured area so it can heal It's also very important to stop smoking and drinking alcohol Prevent complications (bleeding, perforation, penetration, obstruction)

Antibiotic medications. Doctors use combinations of antibiotics to treat H. pylori because one antibiotic alone isn't always sufficient to kill the organism. Acid blockers. Acid blockers also called histamine (H-2) blockers reduce the amount of hydrochloric acid released into digestive tract, which relieves ulcer pain and encourages healing. Antacids. An antacid may be taken in addition to an acid blocker or in place of one. Instead of reducing acid secretion, antacids neutralize existing stomach acid and can provide rapid pain relief.

Bowel rest : Bed rest and clear fluids with no food at all for a few days. Nasogastric tube : Placement of a thin, flexible tube through your nose and down into your stomach. This also relieves pressure on the stomach and helps it heal. Urgent endoscopy or surgery if indicated: Damaged, bleeding blood vessels can usually be repaired with an endoscope.

Surgery VagotomyAntrectomy Pyloroplasty Tying off an artery AcupunctureChiropracticHomeopathyHerbs Other modes Of treatment

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