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Peptic Ulcer Disease

Objective

At the end of this lecture, student will be able to

• Define peptic ulcer disease

• Explain the etiology of peptic ulcer disease

• Describe the pathophysiology of peptic ulcer disease

Peptic Ulcer

• Breach in the mucosa of the alimentary tract, which extends through the muscularis mucosa into the submucosa or deeper

• Chronic and most often solitary, lesions

• Any portion of gastrointestinal tract exposed to the aggressive action of acid-peptic juices

• Erosion of GI mucosa resulting from digestive action of HCl and pepsin

Duodenal vs gastric ulcers

	DUODENAL	GASTRIC
INCIDENCE	More common	Less common
ANATOMY	First part of duodenum – anterior wall	Lesser curvature of stomach
DURATION	Acute or chronic	Chronic
MALIGNANCY	Rare	Benign or malignant

Peptic ulcer

Imbalance between aggressive & protective factors

Aggressive factors

Gastric acid

Proteolytic enzyme

Protective factors

Mucosal layer

Bicarbonate secretion

Prostaglandins

Risk factors of peptic ulcers

• Helicobacter pylori

• Non Steroidal Anti-inflammatory Drugs

• Steroid therapy

• Smoking and Excess alcohol intake

• Genetic factors

• Zollinger Ellison syndrome – rare syndrome caused by gastrin-secreting tumour

• Blood group O and Hyperparathyroidism

Pathophysiology of peptic ulcers

Gastric acid and pepsin

• Potential for producing mucosal damage is related to the secretion of gastric (hydrochloric) acid and pepsin

• Hydrochloric acid – parietal cells – receptors for histamine, gastrin, and acetylcholine

• Increased acid secretion – duodenal ulcers – HP infection

• Patients with ZES have gastric acid hypersecretion resulting from a gastrin-producing tumor

• Patients with gastric ulcer – normal or reduced rates of acid secretion

Mucosal defense mechanisms

• Protect the gastroduodenal mucosa from noxious endogenous and exogenous substances

• Bicarbonate barrier protect the stomach from the acidic contents

• Epithelial cell restitution, growth, and regeneration

• Maintenance of mucosal integrity and repair is mediated by the production of endogenous prostaglandins

H. pylori infection

Mechanisms include:

1) Direct mucosal damage

2) Alterations in the host immune/inflammatory response

3) Hypergastrinemia leading to increased acid secretion

• Virulence factors (vacuolating cytotoxin, cytotoxin-associated gene protein, and growth inhibitory factor)

• Elaborating bacterial enzymes (lipases, proteases, and urease), and adherence

• Lipases and proteases degrade gastric mucus

• Ammonia produced by urease – toxic to epithelial cells

• Bacterial adherence enhances uptake of toxins into gastric epithelial cells

NSAID Induced

• Direct or topical irritation of the gastric epithelium and

• Systemic inhibition of endogenous mucosal prostaglandin synthesis

• Inhibit both COX-1 and COX-2 to varying degrees

• Neutrophil adherence may damage the vascular endothelium

• Lead to a reduction in mucosal blood flow

• Liberate oxygen-derived free radicals and proteases

Symptoms of peptic ulcers

• Abdominal pain that is often epigastric – burning – vague discomfort, abdominal fullness, or cramping

• A typical nocturnal pain that awakens the patient from sleep

• Severity of ulcer pain varies from patient to patient

• May be seasonal, occurring more frequently in the spring or fall

• Episodes of discomfort usually occur in clusters lasting up to a few weeks followed by a pain-free period or remission lasting from weeks to years

• Heartburn, belching, and bloating often accompany the pain

• Nausea, vomiting, and anorexia

Complications of peptic ulcers

• Obstruction – pyloric stenosis and duodenal stenosis

• Hemorrhage – blood in stools; if chronic – leads to anemia

• Perforation

• Malignant transformation to carcinoma

Seeking Treatment

1. Medications

Doctors often prescribe medications to treat peptic ulcers. These may include antibiotics to eliminate H. pylori, proton pump inhibitors (PPIs) to reduce stomach acid, and antacids to alleviate symptoms.

2. Lifestyle Changes

In addition to medications, making certain lifestyle changes can help manage peptic ulcers. This includes quitting smoking, reducing alcohol intake, and avoiding NSAIDs.

3. Surgery

In severe cases where medications and lifestyle changes don’t provide relief, surgery may be necessary to remove the ulcer or repair the damaged tissue.

Preventing Peptic Ulcers

1. H. pylori Screening

Regular screening for H. pylori infection is essential, especially for those with a family history of ulcers or a known exposure to the bacterium.

2. Medication Use

If you need to take NSAIDs for a medical condition, consult with your healthcare provider and consider protective medications to reduce the risk of ulcers.

3. Healthy Eating Habits

Maintain a balanced diet rich in fruits, vegetables, and fiber. Avoid spicy foods and large meals, as these can exacerbate ulcer symptoms.

Summary

• Ulcers are defined as a breach in the mucosa of the alimentary tract, which extends through the muscularis mucosa into the submucosa or deeper

• Etiological factors are helicobacter pylori infection, nonsteroidal anti-inflammatory drugs, critical illness, hypersecretion of gastric acid , viral infections ,vascular insufficiency

• HP infection alters host inflammatory response and damages epithelial cells directly by cell-mediated immune system whereas NSAID cause direct irritation to epithelium and decrease PGE2

FAQs

Are all stomach pains indicative of peptic ulcers? Not all stomach pains are due to peptic ulcers. However, if you experience persistent, burning abdominal pain, it’s advisable to consult a healthcare professional for evaluation.
Can stress cause peptic ulcers? While stress can exacerbate ulcer symptoms, it is not a direct cause of peptic ulcers. They are primarily caused by factors like H. pylori infection and NSAID use.
Is surgery the only option for severe peptic ulcers? Surgery is considered when other treatments are ineffective. It’s not the first choice and is typically reserved for cases where complications like bleeding or perforation occur.
How long does it take to heal a peptic ulcer with medication? The healing time varies from person to person. It can take several weeks to a few months for peptic ulcers to heal with medication and lifestyle changes.
Can I prevent peptic ulcers if I have a family history of the condition? While a family history increases your risk, following preventive measures like H. pylori screening and healthy eating habits can help reduce your chances of developing peptic ulcers.