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Peptic Ulcers

Peptic ulcers, which are circumscribed lesions in the mucosal membrane, can develop in the lower esophagus, stomach, duodenum, or jejunum. The major forms are duodenal ulcer and gastric ulcer; both are chronic conditions.

Duodenal ulcers, which account for about 80% of peptic ulcers, affect the proximal part of the small intestine. These ulcers, which occur most commonly in men between ages 20 and 50, follow a chronic course characterized by remissions and exacerbations. About 5% to 10% of patients with duodenal ulcers develop complications that necessitate surgery.

Gastric ulcers, which affect the stomach mucosa, are most common in middle-aged and elderly men, especially among those who are poor and undernourished. This kind of ulcer also tends to occur in chronic users of aspirin or alcohol.

Causes

Non-cancerous (benign) gastric ulcers are caused by an imbalance between stomach acid, an enzyme called pepsin, and the natural defenses of the stomach's lining. This imbalance leads to inflammation, which can be made worse by aspirin and nonsteroidal anti-inflammatory medications (NSAIDs) such as ibuprofen.

Signs and Symptoms

Typically, the patient describes periods of exacerbation and remission of his symptoms, with remissions lasting longer than exacerbations. Investigation of the patient's history may reveal possible causes or predisposing factors, such as smoking, use of aspirin or other medications, and associated disorders.

The patient with a gastric ulcer may report a recent loss of weight or appetite. He may explain that he doesn't feel like eating or that he has developed an aversion to food because eating causes discomfort. He may have pain in the left epigastrium, which he describes as heartburn or indigestion. His discomfort may be accompanied by a feeling of fullness or distention. Commonly, the onset of pain signals the start of an attack.

Symptoms of the two types of ulcers are often so similar that the source of the ulcer isn't discernible by examination. The patient's history helps distinguish between a gastric and a duodenal ulcer. Ask the patient whether his pain worsens after eating or is relieved by it. In the patient with a gastric ulcer, eating often triggers or aggravates pain. Conversely, food often relieves the pain of a duodenal ulcer. Also inquire whether the patient has experienced nocturnal pain that disrupts his sleep. The patient with a duodenal ulcer reports waking up because of pain; the patient with a gastric ulcer doesn't.

The patient with a duodenal ulcer may have epigastric pain that he describes as sharp, gnawing, or burning. Alternatively, he may describe the pain as boring or aching and poorly defined. Or he may liken it to a sensation of hunger, abdominal pressure, or fullness. Typically, pain occurs 90 minutes to 3 hours after eating. Because eating often reduces the pain of a duodenal ulcer, the patient may report a recent weight gain. Vomiting and other digestive disturbances are rare in these patients.

If the patient is anemic from blood loss, you may notice pallor on inspection. Palpation in the midline and midway between the umbilicus and the xiphoid process may disclose epigastric tenderness. Auscultation may reveal hyperactive bowel sounds.

Diagnostic tests

Barium swallow or upper GI and small-bowel series may reveal the presence of the ulcer. This is the initial test performed on a patient whose symptoms aren't severe.

Upper GI endoscopy or esophagogastroduodenoscopy confirms the presence of an ulcer and permits cytologic studies and biopsy to rule out H. pylori or cancer. Endoscopy is the major diagnostic test for peptic ulcers.

Upper GI tract X-rays reveal mucosal abnormalities.

Laboratory analysis may disclose occult blood in stools.

IgA anti-H. pylori test on a venous blood sample can be used to detect antibodies to H. pylori accurately

Serologic testing may disclose clinical signs of infection such as an elevated white blood cell count. Gastric secretory studies show hyperchlorhydria. Carbon 13 ( 13C) urea breath test results reflect activity of H. pylori. (H. pylori contains the enzyme urease, which breaks down orally administered urea containing the radioisotope 13C before it's absorbed systemically. Low levels of 13C in exhaled breath point to H. pylori infection.)

Treatment

Medical management is essentially symptomatic, emphasizing drug therapy, physical rest, dietary changes, and stress reduction. For patients with severe symptoms or complications, surgery may be required.

The goal of drug therapy is to eradicate H. pylon reduce gastric secretions, protect the mucosa from further damage, and relieve pain. Medications may include:

  • bismuth and two other antimicrobial agents, usually tetracycline or amoxicillin and metronidazole
  • antacids to reduce gastric acidity
  • histamine-2 receptor antagonists, such as cimetidine or ranitidine, to reduce gastric secretion for short-term therapy (up to 8 weeks), or gastric acid pump inhibitor (lansoprazole) for 4 weeks
  • coating agents, such as sucralfate, for duodenal ulcers (Sucralfate forms complexes with proteins at the base of an ulcer, making a protective coat that prevents further digestive action of acid and pepsin.)
  • antisecretory agents, such as misoprostol. if the ulceration resulted from NSAID use and the NSAID must be continued for another condition such as arthritis
  • sedatives and tranquilizers, such as chlordiazepoxide and phenobarbital, for patients with gastric ulcers
  • anticholinergics, such as propantheline, to inhibit the vagus nerve effect on the parietal cells and reduce gastrin production and excessive gastric activity in duodenal ulcers. (These drugs are usually contraindicated in gastric ulcers.)

Standard therapy also includes physical rest and, decreased activity, which help decrease the amount of gastric secretion. Diet therapy may consist of eating six small meals daily (or small hourly meals) rather than three regular meals. Some doctors prescribe a milk and cream or bland diet, but the value of these measures is controversial.

If GI bleeding occurs, emergency treatment begins with passage of a nasogastric (NG) tube to allow iced saline lavage, possibly containing norepinephrine. Gastroscopy allows visualization of the bleeding site and coagulation by laser or cautery to control bleeding. This therapy allows surgery to be postponed until the patient's condition stabilizes.

Surgery is indicated for perforation, unresponsiveness to conservative treatment, suspected cancer, and other complications. The type of surgery chosen for peptic ulcers depends on thelocation and extent of the disorder. Major operations include bilateral vagotomy, pyloroplasty, and gastrectomy.

Prevention
If you are at risk for ulcers, use caution when taking aspirin and NSAIDs.

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