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Peptic Ulcer Disease

Peptic Ulcer Disease. Biol E-163 12/11/06. From: Current Diagnosis & Treatment in Gastroenterology - 2nd Ed. (2003). Peptic Ulcer. Erosion in a segment of the GI mucosa that penetrates through the muscularis mucosae. gastric antrum ulcer. duodenal bulb ulcer that is bleeding.

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Peptic Ulcer Disease

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  1. Peptic Ulcer Disease Biol E-163 12/11/06

  2. From: Current Diagnosis & Treatment in Gastroenterology - 2nd Ed. (2003)

  3. Peptic Ulcer • Erosion in a segment of the GI mucosa that penetrates through the muscularis mucosae gastric antrum ulcer duodenal bulb ulcer that is bleeding From: Current Diagnosis & Treatment in Gastroenterology - 2nd Ed. (2003)

  4. Etiology • H. pylori infection • 70-90% of gastric ulcers • 80-90% of duodenal ulcers • NSAID use • Cigarette smoking • Increased risk of developing ulcers • impairs healing • increases incidence of recurrence • Family history • May reflect genetic susceptibility or intrafamilial H. pylori infection

  5. Pathogenesis • Associated with amount of acid and degree of activation of pepsinogen within the gastric lumen • Pepsinogen = precursor to protein-digesting enzyme that is activated to pepsin by the acid environment of the stomach • Mechanism of H. pylori: • Not understood why/how infection weakens the gastric mucosal layer to be damaged by acid • Mechanism of NSAID use: • Inhibition of prostaglandin synthesis • Prostaglandins stimulate mucus and bicarbonate secretion, and enhance surface hydrophobicity • Can also increase risk of gastric bleeding by interfering with platelet function (necessary for blood clotting)

  6. Symptoms • Depend on ulcer location and age • Pain (most common) • often relieved by antacids • usually chronic and recurrent • Many patients have few or no symptoms • especially the elderly • Gastric ulcers • inconsistent pattern of symptoms • eating can either ameliorate or exacerbate symptoms • Duodenal ulcers • more consistent pain • common at night and relieved by food

  7. Diagnosis • Patient history • Confirmed by endoscopy • Biopsy ulcer to determine if malignant • Definitively diagnose H. pylori infection

  8. Complications (1) • Hemorrhage • Vomiting of blood or passage of bloody stool • Penetration • Penetrates stomach wall but does not leak into peritoneal cavity • Intense persistent pain • Diagnosis confirmed by CT or MRI • Free perforation • Perforates the stomach wall and into peritoneal cavity • Sudden, intense, continuous gastric pain that spreads throughout abdomen • Shock may occur, characterized by increased pulse rate, decreased BP, decreased urine output • Diagnosis confirmed by x-ray (free air space under diaphragm or peritoneal cavity)

  9. Complications (2) • Gastric outlet obstruction • Caused by scarring, spasm, or inflammation from ulcer • Recurrent, large-volume vomiting, often at end of day • Diagnosis confirmed by physical exam, gastric aspiration (>200 mL fluid after fasting overnight), or x-ray • Recurrence • Common risk factors: persistant H. pylori infection, NSAID use, smoking • 1-yr recurrence rate is <10% when H. pylori is eradicated and >60% when it is not • Stomach cancer • People with H. pylori-associated ulcers have 3 to 6 fold increased chance of malignancy later in life • No increased risk of cancer for ulcers associated with other etiologies

  10. Treatments • Reduce gastric acidity • Histamine, acetylcholine, and gastrin stimulate HCl secretion from parietal cells • Histamine (H2) antagonists: reduce histamine production, which also blocks effects of acetylcholine, and gastrin • Antibiotics to rid H. pylori infection • Discontinue smoking • Surgery • Last resort • Most applicable to complications that don’t respond to drug therapy (for example: penetration, free perforation, obstruction) • Procedure involves reduction of acid secretion and while ensuring gastric drainage

  11. Symptoms After Surgery (1) After resective surgery, up to 30% of patients have significant symptoms • Weight loss • Maldigestion • Anemia (iron or vitamin B12 deficiency) • Dumping syndrome • Weakness, dizziness, sweating, nausea, vomiting, and palpitation that occurs soon after eating

  12. Symptoms After Surgery (2) • Reactive hypoglycemia (aka late dumping) • Rapid emptying of carbs from the gastric pouch • High peaks in glucose stimulate over-release of insulin  hypoglycemia several hours after meal • Mechanical problems • Decrease in motor contractions • Diarrhea • Ulcer recurrence

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