Peptic Ulcer Disease

Definition and Causes:

DEFINITION:

Erosion of the lining of the stomach causes a gastric ulcer (GU), while the erosion of the lining of the first portion of the small intestine (the duodenum) causes a duodenal ulcer (DU). Peptic ulcer disease (PUD) refers to either GU or DU.

CAUSES:

Common causes:

• Inflammation of the lining of the stomach and/or duodenum due to bacterial infection (H. pylori bacteria)
• Medication use: Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, aspirin, naproxen

Less common causes:

• Other drugs, e.g. steroids
• Radiation
• Chemotherapy
• Chronic kidney disease
• Overproduction of stomach acid

Symptoms:

Stomach pain (dull ache or burning pain) is the most common complaint. Occurs anywhere in the center of the abdomen. It may begin between meals or flare up at night, during sleep. The duration of the pain is variable. Pain may relieve with antacids or temporarily with the consumption of food.

Other symptoms of peptic ulcers may include

• Nausea
• Vomiting (with blood in severe cases)
• Indigestion
• Blood in feces (or blackening of feces)
• Unexplained weight-loss
• Poor appetite
• Bloating
• Burping

The following symptoms may indicate the need for prompt medical attention:

• Sudden, sharp persistent abdominal pain
• Black or bloody stools
• Blood in vomit or if vomit that looks like coffee grounds

These symptoms might suggest:

• Broken blood vessel due to ulcer, or
• The ulcer has perforated (eroded through and through) the lining of the stomach

Investigations and Treatment:

Physical Exam:

Blood pressure, heart rate, temperature, abdominal examination

Investigation:

Labs:

• Complete blood count (CBC)
• Urea breath test (UBT)
• Stool antigen test (SAT): generally considered if the UBT is not available
• ELISA techniques

Endoscopy:

The patient is given a mild sedative/anesthetic to help relaxation and induce sleep. A thin tube with a camera at the tip is inserted into the patient’s throat and passed down the esophagus into the stomach and duodenum. This allows doctors to observe and examine the lining of the alimentary canal and biopsy any suspicious appearing areas. The tissue sample taken during the biopsy can be sent to a laboratory to test for bacteria and cancer (if this is suspected).

Upper gastrointestinal (G.I.) examination:

The patient ingests a substance called barium which quotes the lining of the esophagus, stomach, and duodenum. Chest and abdominal x-rays can be used to identify the barium and observe for areas of erosion (ulcers).

TREATMENT:

PUD is treated according to its underlying cause:

• Bacterial (H. pylori) associated ulcer
• NSAIDs (e.g. aspirin) associated ulcers
• Refractory (resistant to treatment) ulcers
• Lifestyle (diet) modification

General measures:

• Diet modification: Patients are normally recommended to increase their liquid intake and reduce the consumption of spicy foods
• Antibiotics may be administered to eliminate the H.pylori bacterial infection
• Antacids and acid blockers are used to neutralize the effects of the acid that is naturally produced in the stomach, and hence reduce pain

A) H. pylori-associated ulcers:

Goal is to relieve gastrointestinal discomfort, promote healing, and cure the infection.

Strategy:

1. Medications to reduce stomach acid production Plus
2. Antibiotics Plus
3. Medications to coat and protect the lining of the stomach or duodenum

B) NSAIDs (e.g. aspirin, ibuprofen, naproxen) associated ulcers:

1. Discontinue offending medications
2. Use of medications to reduce stomach acid production
3. Consider additional investigations for other causes if symptoms persist

C) Refractory ulcers:

Patients with recurrent ulcers, who are H. pylori bacteria negative or have failed attempts to eradicate the bacteria, may require long term therapy with medications to reduce stomach acid.

D) Non-pharmacological (lifestyle modification) therapy includes:

• Quit smoking
• Avoid excess alcohol
• Dietary modification (eliminate spicy foods)
• Adequate rest
• Compliance with drug therapy and long-term follow-up care (as required)

Most commonly used Medications

Risk Factors and Prevention:

Risk Factor Management:

• Smoking cessation
• Avoidance of stress
• Avoid excess alcohol, caffeine
• Avoid spicy foods
• Have meals on time

Outcome:

• Peptic ulcers tend to develop again if left untreated
• With proper treatment and adherence to recommendations, relapses are unlikely