Peptic Ulcer

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Peptic Ulcer Disease::

Peptic Ulcer Disease: Dr. J.H. Barnard Dept. of Surgery

Historical Aspects::

Historical Aspects: The clinical presentation, diagnosis, treatment for gastric vs. duodenal ulcers are different. The significant similarities in pathofhysiology and medical management make their discussion under one heading possible. Both gastric and duodenal ulcers are being referred to as peptic, although most attention is focused on acid and H.P infection. Acid + pepsin is much more ulcerogenic than acid alone, thus the peptic label is still appropriate.

Incidence::

Incidence: From the1900’s to the 1970’s occurrence increased steadily. Since then the incidence, especially duodenal ulcers, has been declining in the U.S. Some of this is because of better diagnosis, allowing doctors to differentiate ulcers from other causes of dyspepsia. The tendency towards outpatient management of ulcer disease with less patients reflected in statistics may be a reason for declining incidence.

Location and Type of Ulcer::

Location and Type of Ulcer: Type 1: Primary gastric ulcer. Associated with diffuse antral gastritis. Type 2: Gastric ulcers with duodenal ulcers, most likely secondary to duodenal ulcers. Type 3: Prepyloric or channel ulcer. Type 4: Proximal stomach or gastric cardia. Acid hyper secretion common among type 2 and 3 ulcers. Type 1 an 4 pathophysiologycally the same.

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DEEP GASTRIC ULCER

Gastric Ulcer: An ulcer is a sore or hole in the lining of the stomach or duodenum (the first part of the small intestine). (Source: excerpt from Helicobacter pylori Infections (H. pylori) general: DBMD) ... more about Gastric Ulcer. Gastric Ulcer: A gastric ulcer is a break in the normal tissue that lines the stomach. More detailed information about the symptoms, causes, and treatments of Gastric Ulcer is available below. symptoms · Recurrent abdominal pain - dull and burning type pain usually located in epigastric area (area between belly button and rib cage) · Abdominal pain after food · Abdominal pain at night · Blood in vomit · Nausea:

Gastric Ulcer : An ulcer is a sore or hole in the lining of the stomach or duodenum (the first part of the small intestine ). (Source: excerpt from Helicobacter pylori Infections (H. pylori) general: DBMD ) ... more about Gastric Ulcer . Gastric Ulcer: A gastric ulcer is a break in the normal tissue that lines the stomach. More detailed information about the symptoms , causes , and treatments of Gastric Ulcer is available below. symptoms · Recurrent abdominal pain - dull and burning type pain usually located in epigastric area (area between belly button and rib cage) · Abdominal pain after food · Abdominal pain at night · Blood in vomit · Nausea

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Causes of Gastric Ulcer A gastric ulcer is most commonly caused by infection of the stomach lining with Helicobacter pylori bacteria. These bacteria are also found in individuals without ulcers. Other causes include the use of nonsteroidal anti-inflammatory drugs , as well as gastrinomas that secrete an excessive amount of stomach acid. Risk factors for gastric ulcers include smoking, alcohol consumption and a family history of ulcers.

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Duodenal ulcer: Introduction A duodenal ulcer is a particular type of peptic ulcer ( stomach ulcer ) that afflicts the lining of the duodenum . These two types of gastrointestinal ulcers are common causes of abdominal pain or abdominal discomfort . Other possibilities that may need consideration for these symptoms include ulcerative colitis , Crohn's disease , GERD , gastric reflux , heartburn , or other causes of abdominal pain or abdominal symptoms . · Mostly similar to symptoms of peptic ulcers · Abdominal pain · Abdominal pain after meals · Pain below the ribs · Gastrointestinal bleeding

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Treatments for Duodenal ulcer Antibiotics to kill Helicobacter pylori Acid blockers (like cimetidine, ranitidine, or famotidine) Proton pump inhibitors (such as omeprazole) Medications that protect the tissue lining (like sucralfate)

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4.3OESOPHAGEAL ULCERS An esophageal ulcer is a hole in the lining of the esophagus corroded by the acidic digestive juices secreted by the stomach cells. An esophageal ulcer is usually located in the lower section of your esophagus. It is often associated with chronic gastroesophageal reflux disease (GERD). Esophageal ulcers are not contagious. You cannot catch them from someone else. The direct cause of esophageal ulcers is the destruction of the lining of the esophagus H. pyloridus bacteria. H. pyloridus bacteria is usually found in the stomach.

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4MECKEL’S DIVERTICULUM Meckel's diverticulum is a saclike outpouching of the wall of the small intestine present in some children at birth. Most children do not have symptoms, but sometimes painless rectal bleeding occurs or the diverticulum becomes infected. Doctors base the diagnosis on symptoms, the results of a radionuclide scan, and sometimes ultrasonography. A bleeding diverticulum or one that causes symptoms must be surgically removed.

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symptoms and Diagnosis Most children with Meckel's diverticulum have no symptoms, and many adults learn they have the condition only after surgeons discover it while performing surgery for another reason. The most common symptom among children younger than 5 years is painless rectal bleeding, which comes from ulcers in the small intestine caused by acid secreted by the diverticulum. Because of the bleeding, stools may appear bright red or brick-colored or currant jelly–colored because of a mixture of blood and mucus. Sometimes, stool appears black because of the breakdown of blood. Only rarely is the bleeding so severe that the child needs emergency surgery..

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BENIGN GASTRIC ULCER

Pathogenesis: HP infection.:

Pathogenesis: HP infection. Described in humans in the first decade of the 20th century. Only in 1983 was it described in association with ulcer disease. HP’s natural habitat is the human stomach. Without treatment infection is lifelong. In developing countries most children are infected by the age of 10. In developed countries there is a clear age related increase. IT has not been proven why most patients with HP do not develop ulcer disease. HP resides in the stomach but causes duodenal ulcers probably by colonizing pockets of metaplastic gastric mucosa.

Pathogenesis:NSAIDS:

Pathogenesis:NSAIDS NSAIDs impair normal mucosal defense. 10-20% of patients will develop gastric ulcers and 4-10 % duodenal ulcers within 3 months of taking NSAIDS. Not all endoscopic ulcers are clinically symptomatic and trials generally overstate the risk. Probably closer to 1% in the first three months. NSAID users develop gastric ulcers twice as common as duodenal ulcers. (HP more duodenal). NSAID ulcers not usually associated with gastritis as is the case with HP infection. When NSAID use is stopped these ulcers do not recur.

Pathogenesis: Acid:

Pathogenesis: Acid Adequate acid necessary for duodenal ulcers. Remember “no acid, no ulcer” withstood the test of time. Acid is a important co-factor in the developing of both duodenal and gastric ulcers.

Pathophysiology::

Pathophysiology: The first line of defense is mucus and bicarbonate secretion. It stabilizes the pH between the lumen and the surface epithelial cells. Mucus gel in patients with HP infection was found to be structurally weak. Duodenal mucus as wel as bicarbonate secretion is reduced in patients who smoke. The second line of defense is the intrinsic epithelial cell defense.The mucosal surface is a barrier to acid back diffusion thus maintaining normal intra cellular pH.

Clinical Presentation::

Clinical Presentation: Patients present with dyspepsia, epigastric pain and or discomfort. Acid may irritate nerve endings or peristaltic waves passing the ulcer may cause discomfort. But there is great overlap in symptoms with non ulcer dyspepsia. 20% of patients will present with serious complications without previous ulcer symptoms. It is said that gastric ulcers present with pain associated or closely followed by eating ,where-as duodenal ulcer pain is relieved by food.

Clinical Presentation::

Clinical Presentation: These two pain processes are very non specific. Pain tend to be chronic and recurrent. The two can generally not be differentiated on clinical grounds alone. Generally gastric ulcers present from age 50-65, where as duodenal ulcers present in the thirties .

Diagnosis::

Diagnosis: Gastroscopy detects 90% of duodenal ulcers and 95% of gastric ulcers. Endoscopy allows a tissue diagnosis to be made. Upper Gastro-intestinal radiography. With double contrast 80-90% can be diagnosed. Certain features may suggest malignancy.

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^ a b "GI Consult: Perforated Peptic Ulcer" . Retrieved 2007-08-26. ^ a b "Peptic Ulcer" . Retrieved 2010-06-18. ^ "Peptic ulcer" . Retrieved 2010-06-18. ^ "Ulcer Disease Facts and Myths" . Retrieved 2010-06-18. ^ Cullen DJ, Hawkey GM, Greenwood DC, et al. (1997). "Peptic ulcer bleeding in the elderly: relative roles of Helicobacter pylori and non-steroidal anti-inflammatory drugs" . Gut 41 (4): 459–62. doi : 10.1136/gut.41.4.459 . PMID 9391242 . PMC 1891536 . ^ "Peptic Ulcer: Peptic Disorders: Merck Manual Home Edition" . Retrieved 2007-10-10. ^ http://www.merck.com/mmhe/sec09/ch121/ch121c.html ^ Johannessen T. "Peptic ulcer disease" . Pasienthandboka REFERENCES

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THE END