Disease or PUD is the most common lesion of the gastrointestinal tract. It affects mostly the stomach or the initial part of the small intestine, the duodenum. However, it can affect any part of the gastrointestinal tract. The ulcer affecting the esophagus (the tube connecting the mouth to the stomach) is known as esophageal ulcer, that affecting the stomach is mostly known as gastric ulcer and the ulcer affecting the duodenum is known as the duodenal ulcer.
Duodenal ulcers are four times more common than the stomach ulcers. About 4% of the stomach ulcers are caused by malignant tumors or gastrinomas. Hence, it is imperative that a biopsy be conducted in case of ulcers to rule out malignancy.
In the United States, about 4 million people have active PUD. A little more than one-third of a million new cases are reported each year. Approximately, 3000 deaths can be attributed to complications from duodenal ulcer and another 3000 deaths are caused by gastric ulcer every year.
Mechanism of the Peptic Ulcer Disease
The stomach wall have cells that secrete protein digesting enzymes and strong acids to break down the food. This acid is basically hydrochloric acid which is very corrosive in nature. To protect the interiors of the digestive tract from the acid, there is a lining of mucus all through it. When due to hyperacidity, presence of bacteria or due to other causes there is erosion on the stomach wall or that of the duodenum, an ulcer is formed. Mucosal erosions equivalent to or greater than 0.5 cm meet the criteria of an ulcer.
Symptoms of Gastrointestinal ulcers
The symptoms of PUD are as follows:
- Abdominal pain, which is more of a burning sensation. The severity of this type of epigastric pain is related to food. The pain in duodenal ulcers generally subsides with the intake of food and that in gastric ulcers becomes more intense with food. The pain may continue even after about three hours of taking food.
- Loss of appetite and weight loss.
- Nausea and vomiting.
- Bloating and feeling of fullness.
- Waterbrash or the increased rush of saliva in the mouth. This happens mostly with acid reflux to help diluting the gastric acid. This leaves a sour taste in the mouth.
- When the ulcer invades through the stomach or intestinal wall, it causes bleeding.
- Hematemesis or blood present in vomit could occur due to bleeding from an ulcer or because of the tears in the tissues of the esophagus due to retching during excessive vomiting.
- Melena or black stools is also indicative of gastrointestinal bleeding. The iron in the hemoglobin in blood present in the feces oxidizes giving it a dark color and foul smell.
- In a rare occurrence, the ulcer can cause perforation in the wall of the gastrointestinal tract. This causes the gastric contents to spill all over the abdomen causing peritonitis or widespread infection. This condition is extremely painful and is a medical emergency. It has the potential of being fatal.
Causes of Peptic Ulcer
The possible causes of PUD are as follows:
The presence of the bacteria helicobacter pylori has been linked to the chronic inflammation of the gut. It is one of the major causes of the said type of ulcers. 60% of gastric ulcers and 90% of duodenal ulcers are found to be caused by it. This bacteria affects the production of gastrin which can go up or down. Gastrin causes the parietal cells in the stomach wall to secrete gastric acid. An increased amount of gastrin in turn, increases the gastric acid and can lead to mucosal erosion and ulcer.
Non Steroidal Inflammatory Drugs
: The second most relevant cause, are the side effects of the category of drugs, namely, Non Steroidal Anti Inflammatory Drugs (NSAID’s). The mucosal membrane that protects the stomach wall is secreted and formed with the aid of certain substances, namely, prostaglandins. NSAID’s affect the production of prostaglandins and causes drug induced ulcers. Pain medications and anti inflammatory drugs are the worst offenders. Women and people above 60 years of age who have a history of prolonged use of NSAIDs are most likely to get it.
: Gastrinomas or tumors arising from the stomach wall can cause it. These tumors increasingly secrete gastrin and result in increased production of the gastric acid causing multiple ulcers. The chances of these tumors being malignant are also present.
- Lifestyle Choices: Lifestyle choices are also thought to aggravate the risks of ulcers. Smoking, alcoholism, spicy and rich food etc increases the risk especially in the presence of Helicobacter Pylori.
: Stress is also considered an increased risk. Psychlogiacal stress may promote or aggravate an existing H. Pylori infection. Patients who are bed ridden for a long time as in burns or are mechanically ventilated may develop ulcers.
The presence of the aforementioned symptoms in a patient above 45 may be a reason enough to order a series of diagnostic tests to confirm the primary diagnosis. In many cases, there would be a serious underlying condition causing the symptoms like stomach cancer. Hence, early detection is the key.
: A procedure, namely, esophagogastroduodenoscopy (EGD) is primarily done to detect the condition. It is a form of an endoscopy whereby a tube with a camera is inserted through the gastrointestinal tract to have a firsthand account of the internal situation. The exact location and the extent of the ulcer are properly gauged. It can also be used to extract a tissue specimen to be tested for malignancy later on.
2.Tests for Helicobacter Pylori
: The presence of helicobacter pylori causing the ulcer needs to be detected. The different tests for that are done are as follows:
- Urea breath test
- Culture and biopsy of the tissue specimen obtained from EGD.
- Blood tests to look for specific antibodies and measure their levels.
- Conducting a Rapid Urease test to look for H.Pylori in the biopsy specimen.
- Stool antigen test.
: An X-ray showing free gas just below the diaphragm could indicate an advanced ulcer. In case of a perforated ulcer, gas is leaked into the peritoneal cavity. The peritoneal cavity otherwise has no air in it. This free floating gas will appear as a cloud in the X-ray enabling the diagnosis.
Complications of the disease
- Bleeding from the ulcerous wound is the most common complication. The bleeding is more severe when the ulcer erodes an important blood vessel like the gastroduodenal artery.
- Perforation of the gastrointestinal wall caused by an advanced and eroding ulcer can bring about a complication with severe consequences. The perforation is followed a spillage of the intestinal contents in the abdomen causing peritonitis, septicemia and death.
- A complication could be the ulcer spreading into the adjacent organs like the liver and the pancreas.
- Healed and scarred tissue from ulcers can cause the duodenum to get constricted causing a gastric outlet obstruction.
- New research has attributed H. Pylori as one of the reasons why gastric ulcers progresses into cancer.
Treatment of Peptic Ulcer Disease
The treatment options of the disease depends on the underlying cause of the disease.
- In case of H.Pylori infection, a combination of two antibiotics (e.g., Tetracycline, Amoxicillin, Clarithromycin and Metronidazole), one proton pump inhibitor (PPI) together with a bismuth compound is administered. In treatment resistant ulcers, the said combination is used with one more antibiotic. In the absence of H.Pylori, high dose of PPI’s are administered over long time.
- Patients below 45 and with symptoms are treated with antacids and H2 antagonists. Ranitidine is a common histamine H2 receptor antagonist and available over the counter. It provides quick relief from symptoms like heartburn, acid reflux from excessive stomach acid production.
- Sucralfate or Carafate is another category of drugs used to treat ulcers. It is a sucrose sulfate- aluminium complex that binds to the mucus lining and creates a protective barrier which does not allow the gastric acid to pass through.
- Perforated ulcer is a medical emergency and should be repaired surgically.
- In case of bleeding ulcers, an endoscopy is used to take care of the bleeding spot by cauterization (an agent like electric current or laser is used to treat the bleeding tissue to stop the bleeding), injection or clipping.
- In NSAID induced ulcer, a drug which has a similar chemical makeup to that of prostaglandin could be used to prevent the occurrence of gastric ulcers. This prostaglandin analogue goes by the name of Misoprostol.
This article intends to give a fair knowledge of the different aspects of the discussed condition but cannot substitute medical advice. In case of symptoms, it is important to consult your physician and receive treatment.