Peptic Ulcers

Peptic ulcers most commonly occur in duodenum and stomach (and rarely in esophagus or even in Meckel's diverticulum).The ulcer is deep erosion in the mucosa that during life affects approximately 10% of population in developed countries.

Causes

The ulcers occur due to imbalance between aggressive and protective factors affecting the mucosa. The most important aggressive factor is acidic gastric content and the most important protective factor is protective layer located in the mucosal surface. When the balance turns in favor of aggressive factors, the risk of ulcers is increased. The most common conditions causing the imbalance are mentioned below.

Food

The risk may be higher in irritating spicy food, excessive intake of alcohol and coffee.

Medications

Non-steroidal anti-inflammatory drugs are quite aggressive against the mucosa of the gastrointestinal tract. This negative effect is potentiated when combined with corticosteroids.

Smoking

Cigarette smoke harms the gastric mucosa and there is reported higher incidence of peptic ulcers in smokers.

Infection by Helicobacter pylori

Helicobacter pylori is a bacterium living in the stomach of a substantial part of the population. Its discovery was awarded by Nobel Prize in 2005. The bacterium is capable to survive even in the aggressive acidic environment of stomach. In the majority of people, the bacterium is not harmful, but in some people it may cause chronic inflammation of mucosa, peptic ulcers or even a stomach cancer.

Hypercalcemia

Increased level of calcium in the blood (hypercalcemia) is associated with higher risk of occurrence of peptic ulcers.

Stress

Stressful situations increase gastric acid formation. However, the term “stress ulcers” means more frequent development of peptic ulcers in hospitalized patients in severe conditions. These conditions cause decrease of blood flow through the mucous membrane through the gastrointestinal mucosa, thereby undermine its natural protection against acid and increase the risk of ulcers.

Zollinger-Ellison syndrome

This syndrome is caused by an excessive production by a hormone known as gastrin that potentiates secretion of gastric acid. The overproduction of this hormone is usually associated with a hormone called gastrinoma. For more information see the text about Zollinger-Ellison syndrome.

Symptoms

The main symptom is recurring abdominal pain, which is located in the upper abdomen. In gastric ulcers, the symptoms occur during eating, while in duodenal ulcers the symptoms occur when fasting. Sometimes, the ulcers may not hurt, but they can bleed causing blood vomiting or melena (or both). Serious complication is a sudden rupture of the ulcer, which causes acute abdominal pain followed by paralytic ileus and peritonitis. Other complications may include penetration of the ulcer into other neighboring organs such as into the pancreas (may cause acute pancreatitis) or intestine (may cause stomach-intestinal fistula).

Diagnosis

The doctor is especially interested in any troubles related to food intake (especially the abdominal pain) or any signs of bleeding into the gastrointestinal tract. The best diagnostic method is the upper GI endoscopy, which allows us to examine the whole upper gastrointestinal tract including the stomach and duodenum. The examination allows us to localize the ulcer, evaluate its size and risk of bleeding. In case we find an ulcer, it is advisable to exclude the presence of Helicobacter pylori. Because some types of stomach cancers may mimic the peptic ulcers, it is necessary to take sample from any peptic ulcer located in stomach for histological examination. The rupture of a peptic ulcer can be quickly diagnosed by abdominal X-ray that may found air in the abdominal cavity.

Prevention

It is recommended to avoid smoking, limit alcohol intake and avoid stressful situations. When the patient regularly uses higher doses of non-steroidal anti-inflammatory drugs or when these drugs are combined with corticosteroids, it is advisable to prescribe preventively at least a small dose of drugs decreasing stomach acidity.

Treatment

The patient with a diagnosed peptic ulcer should for some time avoid spicy food, alcohol and smoking. A bout of abdominal pain may be effectively solved by antacids that quickly decrease the stomach acidity. The best and most commonly drugs aimed to heal any ulcers are proton pump inhibitors. These powerful medications block the secretion of gastric acid, which gives the stomach mucosa enough time to heal. Even large ulcers may disappear with only a small scar.

 

When we discover presence of Helicobacter pylori in a patient with peptic ulcer, it is advisable to eradicate it with antibiotics.

 

Surgical treatment focuses mainly on rupture of peptic ulcers that are solved by a closure of the perforated area. When the ulcer is large, removal of a part of the stomach may be needed.