Peptic Ulcer

Definition:
Peptic ulcers are open sores that develop on the inside lining of your stomach, upper small intestine or esophagus. The most common symptom of a peptic ulcer is pain.Not long ago, the common belief was that peptic ulcers were a result of lifestyle. Doctors now know that a bacterial infection or some medications — not stress or diet — cause most ulcers of the stomach and upper part of the small intestine (duodenum). Esophageal ulcers also may occur and are typically associated with the reflux of stomach acid.

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A peptic ulcer, also known as PUD or peptic ulcer disease, is an ulcer (defined as mucosal erosions equal to or greater than 0.5 cm) of an area of the gastrointestinal tract that is usually acidic and thus extremely painful. As much as 80% of ulcers are associated with Helicobacter pylori, a spiral-shaped bacterium that lives in the acidic environment of the stomach, however only 20% of those cases go to a doctor. Ulcers can also be caused or worsened by drugs such as Aspirin and other NSAIDs. Contrary to general belief, more peptic ulcers arise in the duodenum (first part of the small intestine, just after the stomach) than in the stomach. About 4% of stomach ulcers are caused by a malignant tumor, so multiple biopsies are needed to make sure. Duodenal ulcers are generally benign.

Classification

A peptic ulcer may arise at various locations:

* Stomach (called gastric ulcer)
* Duodenum (called duodenal ulcer)
* Esophagus (called esophageal ulcer)
* Meckel’s Diverticulum (called Meckel’s Diverticulum ulcer)

Signs and symptoms:

Burning pain is the most common peptic ulcer symptom. The pain is caused by the ulcer and is aggravated by stomach acid coming in contact with the ulcerated area. The pain typically may:

* Be felt anywhere from your navel to your breastbone
* Last from a few minutes to many hours
* Be worse when your stomach is empty
* Flare at night
* Often be temporarily relieved by eating certain foods that buffer stomach acid or by taking an acid-reducing medication
* Come and go for a few days or weeks

Less often, ulcers may cause severe signs or symptoms such as:

* The vomiting of blood — which may appear red or black
* Dark blood in stools or stools that are black or tarry
* Nausea or vomiting
* Unexplained weight loss
* Chest pain

A history of heartburn, gastroesophageal reflux disease (GERD) and use of certain forms of medication can raise the suspicion for peptic ulcer. Medicines associated with peptic ulcer include NSAID (non-steroid anti-inflammatory drugs) that inhibit cyclooxygenase, and most glucocorticoids (e.g. dexamethasone and prednisolone).

In patients over 45 with more than 2 weeks of the above symptoms, the odds for peptic ulceration are high enough to warrant rapid investigation by EGD (see below).

The timing of the symptoms in relation to the meal may differentiate between gastric and duodenal ulcers: A gastric ulcer would give epigastric pain during the meal, as gastric acid is secreted, or after the meal, as the alkaline duodenal contents reflux into the stomach. Symptoms of duodenal ulcers would manifest mostly before the meal — when acid (production stimulated by hunger) is passed into the duodenum. However, this is not a reliable sign in clinical practice.
Causes:
Depending on their location, peptic ulcers have different names:

* Gastric ulcer. This is a peptic ulcer that occurs in your stomach.
* Duodenal ulcer. This type of peptic ulcer develops in the first part of the small intestine (duodenum).
* Esophageal ulcer. An esophageal ulcer is usually located in the lower section of your esophagus. It’s often associated with chronic gastroesophageal reflux disease (GERD).

The culprit in most cases
Although stress and spicy foods were once thought to be the main causes of peptic ulcers, doctors now know that the cause of most ulcers is the corkscrew-shaped bacterium Helicobacter pylori (H. pylori).

H. pylori lives and multiplies within the mucous layer that covers and protects tissues that line the stomach and small intestine. Often, H. pylori causes no problems. But sometimes it can disrupt the mucous layer and inflame the lining of the stomach or duodenum, producing an ulcer. One reason may be that people who develop peptic ulcers already have damage to the lining of the stomach or small intestine, making it easier for bacteria to invade and inflame tissues.

H. pylori is a common gastrointestinal infection around the world. In the United States, one in five people younger than 30 and half the people older than 60 are infected. Although it’s not clear exactly how H. pylori spreads, it may be transmitted from person to person by close contact, such as kissing. People may also contract H. pylori through food and water.

H. pylori is the most common, but not the only, cause of peptic ulcers. Besides H. pylori, other causes of peptic ulcers, or factors that may aggravate them, include:

*Regular use of pain relievers. Nonsteroidal anti-inflammatory drugs (NSAIDs) can irritate or inflame the lining of your stomach and small intestine. The medications are available both by prescription and over-the-counter. Nonprescription NSAIDs include aspirin, ibuprofen (Advil, Motrin, others), naproxen (Aleve) and ketoprofen (Orudis KT). To help avoid digestive upset, take NSAIDs with meals.

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NSAIDs inhibit production of an enzyme (cyclooxygenase) that produces prostaglandins. These hormone-like substances help protect your stomach lining from chemical and physical injury. Without this protection, stomach acid can erode the lining, causing bleeding and ulcers.
* Smoking. Nicotine in tobacco increases the volume and concentration of stomach acid, increasing your risk of an ulcer. Smoking may also slow healing during ulcer treatment.
* Excessive alcohol consumption. Alcohol can irritate and erode the mucous lining of your stomach and increases the amount of stomach acid that’s produced. It’s uncertain, however, whether this alone can progress into an ulcer or whether other contributing factors must be present, such as H. pylori bacteria or ulcer-causing medications, such as NSAIDs.
* Stress. Although stress per se isn’t a cause of peptic ulcers, it’s a contributing factor. Stress may aggravate symptoms of peptic ulcers and, in some cases, delay healing. You may undergo stress for a number of reasons — an emotionally disturbing circumstance or event, surgery, or a physical trauma, such as a burn or other severe injury.

Complications:

* Gastrointestinal bleeding is the most common complication. Sudden large bleeding can be life threatening[2]. It occurs when the ulcer erodes one of the blood vessels.
* Perforation (a hole in the wall) often leads to catastrophic consequences. Erosion of the gastro-intestinal wall by the ulcer leads to spillage of stomach or intestinal content into abdominal cavity. Perforation at the anterior surface of stomach leads to acute peritonitis, initially chemical and later bacterial peritonitis. Often first sign is sudden intense abdominal pain. Posterior wall perforation leads to pancreatitis; pain in this situation often radiates to back.
* Penetration is when the ulcer continues into adjacent organs such as liver and pancreas[3].
* Scarring and swelling due to ulcers causes narrowing in the duodenum and gastric outlet obstruction. Patient often presents with severe vomiting.
* Pyloric Stenosis

Diagnosis:
n order to detect an ulcer, your doctor may have you undergo the following diagnostic tests:

* Upper gastrointestinal (upper GI) X-ray. Your doctor may begin with this test, which outlines your esophagus, stomach and duodenum. During the X-ray, you swallow a white, metallic liquid (containing barium) that coats your digestive tract and makes an ulcer more visible. An upper GI X-ray can detect some ulcers, but not all.
* Endoscopy. This procedure may follow an upper GI X-ray if the X-ray suggests a possible ulcer, or your doctor may perform endoscopy first. In this more sensitive procedure, a long, narrow tube with an attached camera is threaded down your throat and esophagus into your stomach and duodenum. With this instrument, your doctor can view your upper digestive tract and identify an ulcer.

If your doctor detects an ulcer, he or she may remove small tissue samples (biopsy) near the ulcer. These samples are examined under a microscope to rule out cancer. A biopsy can also identify the presence of H. pylori in your stomach lining. Depending on where the ulcer is found, your doctor may recommend a repeat endoscopy after two to three months to confirm that the ulcer is healing.

Additional tests
In addition to a biopsy, these other tests can determine if the cause of your ulcer is H. pylori infection:

* Blood test. This test checks for the presence of H. pylori antibodies. A disadvantage of this test is that it sometimes can’t differentiate between past exposure and current infection. After H. pylori bacteria have been eradicated, you may still have a positive result for many months.
* Breath test. This procedure uses a radioactive carbon atom to detect H. pylori. First, you blow into a small plastic bag, which is then sealed. Then, you drink a small glass of clear, tasteless liquid. The liquid contains radioactive carbon as part of a substance (urea) that will be broken down by H. pylori. Thirty minutes later, you blow into a second bag, which also is sealed. If you’re infected with H. pylori, your second breath sample will contain the radioactive carbon in the form of carbon dioxide.

The advantage of the breath test is that it can monitor the effectiveness of treatment used to eradicate H. pylori, detecting when the bacteria have been killed or eradicated. With the blood test, H. pylori antibodies may sometimes still be present a year or more after the infection is gone.
* Stool antigen test. This test checks for H. pylori in stool samples. It’s useful both in helping to diagnose H. pylori infection and in monitoring the success of treatment.

Treatment:
Younger patients with ulcer-like symptoms are often treated with antacids or H2 antagonists before EGD is undertaken. Bismuth compounds may actually reduce or even clear organisms.

Patients who are taking nonsteroidal anti-inflammatories (NSAIDs) may also be prescribed a prostaglandin analogue (Misoprostol) in order to help prevent peptic ulcers, which may be a side-effect of the NSAIDs.

When H. pylori infection is present, the most effective treatments are combinations of 2 antibiotics (e.g. Clarithromycin, Amoxicillin, Tetracycline, Metronidazole) and 1 proton pump inhibitor (PPI), sometimes together with a bismuth compound. In complicated, treatment-resistant cases, 3 antibiotics (e.g. amoxicillin + clarithromycin + metronidazole) may be used together with a PPI and sometimes with bismuth compound. An effective first-line therapy for uncomplicated cases would be Amoxicillin + Metronidazole + Rabeprazole (a PPI). In the absence of H. pylori, long-term higher dose PPIs are often used.

Treatment of H. pylori usually leads to clearing of infection, relief of symptoms and eventual healing of ulcers. Recurrence of infection can occur and retreatment may be required, if necessary with other antibiotics. Since the widespread use of PPI’s in the 1990s, surgical procedures (like “highly selective vagotomy”) for uncomplicated peptic ulcers became obsolete.

Perforated peptic ulcer is a surgical emergency and requires surgical repair of the perforation. Most bleeding ulcers require endoscopy urgently to stop bleeding with cautery or injection.

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Disclaimer: This information is not meant to be a substitute for professional medical advise or help. It is always best to consult with a Physician about serious health concerns. This information is in no way intended to diagnose or prescribe remedies.This is purely for educational purpose

Sources:
http://en.wikipedia.org/wiki/Peptic_ulcer
http://www.mayoclinic.com/health/peptic-ulcer/DS00242

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