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Alternative Names Ulcer – peptic; Ulcer – duodenal or gastric; Duodenal ulcer
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A peptic ulcer is erosion in the lining of the stomach or duodenum (the first part of the small intestine). The word â€œpepticâ€ refers to pepsin, a stomach enzyme that breaks down proteins. If a peptic ulcer is located in the stomach it is called a gastric ulcer.
Small ulcers may not cause any symptoms. Large ulcers can cause serious bleeding. Most ulcers occur in the first layer of the inner lining. A hole that goes all the way through is called a perforation of the intestinal lining. A perforation is a medical emergency.
It is also known as PUD or peptic ulcer disease is an ulcer 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 (for it is not a dangerous case if caught in time and can be treated with surgery). 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.
Normally, the lining of the stomach and small intestines have protection against the irritating acids produced in your stomach. For a variety of reasons, the protective mechanisms may become faulty, leading to a breakdown of the lining. This results in inflammation (gastritis ) or an ulcer.
The most common cause of such damage is infection of the stomach with a bacterium called Helicobacter pylori (H.pylori). Most people with peptic ulcers have this organism living in their gastrointestinal (GI) tract. On the other hand, many people have this organism living in their GI tract but they don’t get an ulcer.
Other factors can make it more likely for you to get an ulcer, including:
Using aspirin, ibuprofen, or naproxen
Drinking alcohol excessively
Smoking cigarettes and using tobacco
In addition, if you have a family history of ulcers or you are blood type O, you are more likely to get a duodenal ulcer. There is also a rare condition called Zolliger-Ellison syndrome in which a tumor in the pancreas secretes a substance that causes ulcers throughout the stomach and duodenum.
Many people believe that stress causes ulcers. It is not clear if this is true. While critically ill patients who are on a breathing machine are at risk of so-called â€œstress ulceration,â€ everyday stress at work or home doesn’t appear to cause peptic ulcers.
Abdominal pain is a common symptom but it may not always be present. The abdominal pain from peptic ulcers can differ a lot from person to person. For example, the pain may get better or worse after eating a meal.
Abdominal pain, classically epigastric with severity relating to mealtimes, after around 3 hours of taking a meal (duodenal ulcers are classically relieved by food, while gastric ulcers are exacerbated by it);
Bloating and abdominal fullness
Waterbrash (rush of saliva after an episode of regurgitation to dilute the acid in esophagus)
Nausea, and lots of vomiting
Loss of appetite and weight loss;
Hematemesis (vomiting of blood); this can occur due to bleeding directly from a gastric ulcer, or from damage to the esophagus from severe/continuing vomiting.
Melena (tarry, foul-smelling faeces due to oxidized iron from hemoglobin)
Rarely, an ulcer can lead to a gastric or duodenal perforation. This is extremely painful and requires immediate surgery.
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 â€” when acid (production stimulated by hunger) is passed into the duodenum. However, this is not a reliable sign in clinical practice.
Stress and ulcers:
Despite the finding that a bacterial infection is the cause of ulcers in 80% of cases, bacterial infection does not appear to explain all ulcers and researchers continue to look at stress as a possible cause, or at least a complication in the development of ulcers.
An expert panel convened by the Academy of Behavioral Medicine research concluded that ulcers are not purely an infectious disease and that psychological factors do play a significant role. Researchers are examining how stress might promote H. pylori infection. For example, Helicobacter pylori thrives in an acidic environment, and stress has been demonstrated to cause the production of excess stomach acid.
The discovery that Helicobacter pylori is a cause of peptic ulcer has tempted many to conclude that psychological factors are unimportant. But this is dichotomised thinking. There is solid evidence that psychological stress triggers many ulcers and impairs response to treatment, while helicobacter is inadequate as a monocausal explanation as most infected people do not develop ulcers. Psychological stress probably functions most often as a cofactor with H pylori. It may act by stimulating the production of gastric acid or by promoting behavior that causes a risk to health. Unravelling the aetiology of peptic ulcer will make an important contribution to the biopsychosocial model of disease.
A study of peptic ulcer patients in a Thai hospital showed that chronic stress was strongly associated with an increased risk of peptic ulcer, and a combination of chronic stress and irregular mealtimes was a significant risk factor (PMID 12948263).
A study on mice showed that both long-term water-immersion-restraint stress and H. pylori infection were independently associated with the development of peptic ulcers (PMID 12465722).
An esophagogastroduodenoscopy (EGD), a form of endoscopy, also known as a gastroscopy, is carried out on patients in whom a peptic ulcer is suspected. By direct visual identification, the location and severity of an ulcer can be described. Moreover, if no ulcer is present, EGD can often provide an alternative diagnosis.
The diagnosis of Helicobacter pylori can be by:
Breath testing (does not require EGD);
Direct culture from an EGD biopsy specimen;
Direct detection of urease activity in a biopsy specimen;
Measurement of antibody levels in blood (does not require EGD). It is still somewhat controversial whether a positive antibody without EGD is enough to warrant eradication therapy.
The possibility of other causes of ulcers, notably malignancy (gastric cancer) needs to be kept in mind. This is especially true in ulcers of the greater (large) curvature of the stomach; most are also a consequence of chronic H. pylori infection.
If a peptic ulcer perforates, air will leak from the inside of the gastrointestinal tract (which always contains some air) to the peritoneal cavity (which normally never contains air). This leads to “free gas” within the peritoneal cavity. If the patient stands erect, as when having a chest X-ray, the gas will float to a position underneath the diaphragm. Therefore, gas in the peritoneal cavity, shown on an erect chest X-ray or supine lateral abdominal X-ray, is an omen of perforated peptic ulcer disease.
Exams and Tests :
To diagnose an ulcer, your doctor will order one of the following tests:
An upper GI — a series of x-rays taken after you drink a substance called barium.
An esophagogastroduodenoscopy (EGD) — a special test performed by a gastroenterologist in which a thin tube is inserted through your mouth into the gastrointestinal tract to look at your stomach and small intestines.
During an EGD, the doctor may take a biopsy from the wall of the intestines to test for H. pylori.
Your doctor may also order:
Stool guaiac cards to test for blood in your stool
Hemoglobin test to check for anemia
You should see a doctor if you have symptoms of an ulcer. Treatment often involves a combination of medications to kill the Helicobacter pylori bacteria, reduce acid levels, and protect the GI tract. This combination strategy allows your ulcer to heal and reduces the chance it will come back. Take all of your medications exactly as prescribed.
The medications may include one or more of the following:
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)
Bismuth (may help protect the lining and kill the bacteria)
If a peptic ulcer bleeds a lot, an EGD may be needed to stop the bleeding. If bleeding cannot be stopped using an EGD procedure or the ulcer has caused a perforation, then surgery may be required.
Peptic ulcers tend to come back if untreated. If you follow the treatment instructions from your doctor and take all of your medications, the Helicobacter pylori infection will be eliminated and you are much less likely to get another ulcer. Your symptoms will also improve if you follow some preventive lifestyle steps.
Perforation of the intestine and peritonitis
When to Contact a Medical Professional
Call 911 if you:
Suddenly develop sharp abdominal pain.
Have symptoms of shock like fainting, excessive sweating, or confusion.
Are vomiting blood or have blood in your stool (especially if maroon or dark, tarry black)
Have a rigid, hard abdomen that is tender to touch.
Call your doctor if:
You have ulcer symptoms.
You feel dizzy or lightheaded.
Don’t smoke or chew tobacco.
Avoid aspirin, ibuprofen, and naproxen. Try acetaminophen instead.
In Western countries the prevalence of Helicobacter pylori infections roughly matches age (i.e., 20% at age 20, 30% at age 30, 80% at age 80 etc). Prevalence is higher in third world countries. Transmission is by food, contaminated groundwater, and through human saliva (such as from kissing or sharing food utensils.)
According to Mayo Clinic, however, there is no evidence that the infection can be transmitted by kissing.
A minority of cases of Helicobacter infection will eventually lead to an ulcer and a larger proportion of people will get non-specific discomfort, abdominal pain or gastritis.
In 1997, the Centers for Disease Control and Prevention, with other government agencies, academic institutions, and industry, launched a national education campaign to inform health care providers and consumers about the link between H. pylori and ulcers. This campaign reinforced the news that ulcers are a curable infection, and the fact that health can be greatly improved and money saved by disseminating information about H. pylori.
Helicobacter pylori was rediscovered in 1982 by two Australian scientists Robin Warren and Barry Marshall. In their original paper, Warren and Marshall contended that most stomach ulcers and gastritis were caused by colonization with this bacterium, not by stress or spicy food as had been assumed before.
The H. pylori hypothesis was poorly received, so in an act of self-experimentation Marshall drank a petri-dish containing a culture of organisms extracted from a patient and soon developed gastritis. His symptoms disappeared after two weeks, but he took antibiotics to kill the remaining bacteria at the urging of his wife, since halitosis is one of the symptoms of infection. This experiment was published in 1984 in the Australian Medical Journal and is among the most cited articles from the journal.
In 2005, the Karolinska Institute in Stockholm awarded the Nobel Prize in Physiology or Medicine to Dr. Marshall and his long-time collaborator Dr. Warren “for their discovery of the bacterium Helicobacter pylori and its role in gastritis and peptic ulcer disease”. Professor Marshall continues research related to H. pylori and runs a molecular biology lab at UWA in Perth, Western Australia.
John Lykoudis was a general practitioner in Greece who treated patients from peptic ulcer disease with antibiotics long before it was commonly recognized that bacteria were a dominant cause for the disease .
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