Peptic Ulcer

Introduction:

-mucosal erosions which is equal to or greater than o.5 cm in measurement.

-duodenal ulcer is very common .Most common in 20-45 years old .95% within 2 cm from the pylorus, and 5% are post-bulbar ulcer.

↑numbers of parietal and chief cell

↑parietal cell sensitivity to gastrin

↑gastrin response to meal

↑gastric emptying

↓inhibition of gastrin release to acid

-In fact, peptic ulcers may occur anywhere where pepsin and acid occur together 

Epidemiology

-A common disease in digestive  system

-No data are available about the exact   incidence of peptic ulcer 

-worldwide

Aetiology:

-Hp is an important etiological factor 

-30% of gastric ulcer are due to NSAIDS

-Men are affected 3 times as often as women

-Duodenal ulcer(DU)is 10 times more than gastric ulcer in the young patiets.But in the older age groups the frequency is about equal.

Pathogenesis and pathophysiology :

-PU(peptic ulcer) is caused by an imbalance between secretion of acid and pepsin, and breakdown of mucosal defence.

-An acid environment and reduced mucosal defences provide ideal circumstances for pepsin to cause mucosal ulceration.

-H.pylori uses an antigen adhension molecule (AbaB) to bind to Lewis b antigen on epithelial cells.

-the bacteria stimulates chronic gastritis by producing local inflammatory response probably by expression of bacterial cagA and VacA gene.

Classification:

-Duodenal ulcer

-oesophageal ulcer

-gastric ulcer

-Meckel's diverticulum ulcer

Modified Johnson Classification of peptic ulcers:

Type I: Ulcer along the body of the stomach, most often along the lesser curve at incisura angularis along the locus minoris resistentiae.

Type II: Ulcer in the body in combination with duodenal ulcers. Associated with acid oversecretion.

Type III: In the pyloric channel within 3 cm of pylorus. Associated with acid oversecretion.

Type IV: Proximal gastroesophageal ulcer

Type V: Can occur throughout the stomach. Associated with chronic NSAID use (such as aspirin).

 Special types of ulcers:

Complex ulcer:

     --ulcers occur in both gastric and duodenal mucosa

Ulcer of pyloric canal:

   --usually cause pyloric obstruction

Postbulbar ulcer

Macrosis ulcer:

   --size>2cm

Peptic ulcer in elderly people

Symptomless ulcer

  --half of the NSAIDS-related ulcers are symptomless

Clinical features:

-symptom is the most important clue for clinical diagnosis

-the vast majority of people remains asymptomatic and only the minority develop clinical symptoms.

-Recurrent Abdominal Pain: It is the most common presentation.In gastric ulcer, epigastric pain after around 3 hours of taking a meal. While,in duodenal ulcer, pain is relieved by talking food). occasional vomiting occurs in 40% of the patients.

-bloating and abdominal fullness

-loss of appetite and weight loss

-hematemesis(vomiting of blood), melena

-If perforation, extremely painful and needs immediate surgery

Diagnosis:

-symptom is the most important clue

-Definite diagnosis of peptic ulcer depends on endoscopy examination .May observe ulcer,take biopsy and detect HP infection

-Niche sign observed by x-ray barium meal examination may also provide evidence for definite diagnosis of peptic ulcer.Not as accurate as endoscopy detection.

          First pic:DU under endoscopy ,Second pic:Niche sign under    x-ray barium meal examination

-Hp detection(routine): 

virulence( biopsy specimen of gastric mucosa) 

 Histological examination

 Hp culture

 Rapid urease test

non-virulence:

       13C or 14C  urea breath test

              Hp antigen detection in stool

              Serologic examination of Hp antibody

Differential Diagnosis: 

lPeptic ulcer need to be differentiated from diseases with chronic upper abdominal pain

    Diseases of liver, gallbladder and pancreas,  functional dyspepsia

lAfter the ulcer has been detected by endoscopy examination

    The differential diagnosis of benign and malignant gastric ulcer is very important

Treatment:

Principle:

-Eliminate etiological factors (Hp eradication, stop using NSAIDs)

-Relieve symptoms, facilitate ulcer healing (antiulcer drugs)

-Prevent ulcer recurrence, and prevent or treat complications

1.General treatment

 -Stop smoking, stop drinking ,regular food-intake, et al

        

2. Anti-ulcer treatment 

3. Hp eradication treatment:

Hp must be eradicated in all.

Prevention

Following patients need routine prevention treatment:

lPatients with a history of peptic ulcer

lElderly patients

lPatients using glucocorticosteroid or decoagulant (including low-dosage asprin) together with NSAIDs

Prevention method:

PPI, routine dosage

1.Hp eradication and stop using NSAID may prevent peptic ulcer recurrence

2.Following patients need to maintain long term anti-ulcer treatment to prevent ulcer recurrence:

lPatient who can not stop using NSAIDs

lHp can not be eradicated

lUlcer recurrence after Hp eradication

l Non-Hp and non-NSAIDs ulcer

l Elderly patients

l Patients with serious concomitant disease

3. Prevention method:

    PPI or H2RA, routine dosage

Indication for surgery:

-Hemorrhea, medical treatment is effective

-acute perforation

-cicatricial pyloric obstruction

-gastric ulcer with canceration

-telephium, medical treatment is ineffective