Aims:Definition of peptic ulcer.Location and symptoms.Causes.Types.Complications and treatment.Precautions.

Definition:Peptic ulcer is a hole or open sore in the lining of the stomach, duodenum (beginning of the small intestine) or oesophagus.

"peptic" refers to pepsin: a stomach enzyme that breaks down protein.

An ulcer occurs when the lining of these organs is corroded by acidic digestive juices secreted by the stomach cells.

Location of peptic ulcer: Ulcer may be found :In oesophagus,

stomach and duodenum,

jejunum at multiple levels (Zollinger Ellison syndrome).

SymptomsAbdominal discomfort usually occurs in epigastric area (upper middle part of the abdomen) radiating to the back described as:dull gnawing ache comes and goes for several dayspain may increase when the stomach is empty at night or half to three hours after meal.Pain is relieved by eating & antacid medication.

Other symptoms:

Weight change

Fatigue

Other symptoms:

Bloating

Other symptoms:

Chest pain

Burping

Other symptoms:

Nausea and Anorexia (common with gastric ulcer)

Other symptoms:

Vomiting (relieves episodes of severe pain due to evacuation of gastric acid content).

Less common symptoms:

1-Constipation and 5% of the patients with chronic duodenal ulcers has predominantly colonic symptoms.

Less common symptoms:

2-Heartburn and eructation are also commonly associated with ulcer activity.

NOTE: heartburn is so prominent that the primary disease is thought to be esophageal.

Emergency symptoms:

If you have any of these symptoms call your doctor right away:Sharp sudden persistent stomach.

Emergency symptoms:Bloody or black stools. Bloody vomit or vomit that looks like coffee grounds.

NOTE:

They could be signs of a serious problem such as:

Perforation when the ulcer burrows through the stomach or duodenal wall.

NOTE: Bleeding when the ulcer blocks the path of food

trying to leave the stomach.

Causes of peptic ulcer:While acid is still considered significant in ulcer formation, the leading cause of ulcer disease is currently believed to be infection of the stomach by bacteria called "Helicobacter pyloridus" (H. pylori).

Stress increases HCl secretion.

Chronic use of anti-inflammatory medications, commonly referred to as NSAIDs (Nonsteroidal anti-inflammatory drugs).

H. Pylori Bacterium (helicobacter pylori) The H. pylori bacteria excretes

the enzyme urease, which converts urea into ammonia and

bicarbonate. The release of ammonia ‘neutralize’ the acidic

environment in the stomach, which explains

the difficulty in destroying the H. pylori bacterium.! Ammonia is toxic to the epithelial cells and damages

them; hence the beginning of a stomach ulcer takes its course.

Diagnosing H. pylori:

H. pylori is diagnosed through:

blood, breath, stool, and tissue tests.

Diagnosing H. pylori:

Blood tests are most common. They detect antibodies to H. pylori bacteria. Blood is taken at the doctor's office through a finger stick.

Diagnosing H. pylori:Urea breath tests are an effective diagnostic method for H. pylori. They are also used after treatment to see whether it worked. In the doctor's office, the patient drinks a urea solution that contains a special carbon atom. If H. pylori is present, it breaks down the urea, releasing the carbon. The blood carries the carbon to the lungs, where the patient exhales it. The breath is accurate.

Diagnosing H. pylori:Stool tests detect H. pylori infection in the patient's fecal matter. Helicobacter pylori stool antigen (HPSA) test is accurate for diagnosing H. pylori .Tissue tests are usually done using the biopsy sample that is removed with the endoscope.

No one knows for sure how H. pylori spreads, so prevention is difficult. Researchers are trying to develop a vaccine to prevent infection.Note: H. pylori can be transmitted from person to person through close contact and exposure to vomit.

NSAIDsNSAIDs

NSAIDs are medications for arthritis and other painful inflammatory conditions in the body. Aspirin, Ibuprofen (Motrin), Naproxen (Naprosyn), and Etodolac (Lodine) are a few of the examples of this class of medications. NSAIDs cause ulcers by interfering with prostaglandins in the stomach & prevent PGE2 synthesis.

ProstaglandinsProstaglandinsProstaglandins are substances which are important in helping the gut linings resist corrosive acid damage.

-local prostaglandins production PGE2. HCl Damaging factors. Bicarbonate (production of gastric bicarbonate which is trapped in the mucus layer thus creating a PH gradient from 1-2 at gastric lumen, 6-7 at surface of mucosa). Mucus production (mucus mucopolysaccharides resistant to action of proteolytic enzymes).

Protective

factors

CofactorsCofactors Cigarette smoking is an important cofactor of ulcer formation and ulcer treatment failure. Cigarette smoking increases the risk of ulcer complications. Nicotine is a ganglionic stimulant so it stimulates vagal nerve and increase HCl secretion through acetylcholine.

alcohol intake disrupts mucus secretion and cause mucosal damage.

Coffee Colas, spicy foods, and caffeine

Types of Peptic UlcerTypes of Peptic Ulcer::

DuodenalGastricOesophagalZollinger Ellison syndrome (severe peptic ulcer+gastric hyperacidity, gastrinoma: islet cell tumor in pancreas)Curling's ulcer

Duodenal and Gastric UlcersDuodenal and Gastric Ulcers::

Duodenal ulcerGastric ulcer

-Incidence

Age 30-60Usually 50 years and above

♀:♂ 2-3:1♂:♀ 1:1

80% of peptic ulcers are duodenal

15% of peptic ulcers are gastric

Comparison between Duodenal and Comparison between Duodenal and Gastric UlcerGastric Ulcer::

-Signs and Symptoms

Hypersecretion of HCl

Hyposecretion of HCl

Weight gain Weight loss

Pain 2-3 hrs after meal; often awakened btw 1-2 AM; ingestion of food

relieves pain

Pain occurs 1\2-1 hr after meal; rarely

occurs at night; may be relieved by

vomiting; ingestion of food does not help,

sometimes increases pain

Vomiting uncommonVomiting commonIt perforates more than

gastric ulcerHemorrhage more likely to occur than

with duodenal ulcer.

-Malignancy rare Occasionally takes

place

-Risk factorsH.Pylori, alcohol, smoking, cirrhosis,

stress

H.Pylori, gastritis, alcohol, smoking,

NSAIDs, stress

Esophageal UlcerEsophageal UlcerAn 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 esophagus. Esophageal ulcers are not contagious. Esophageal ulcers may be a symptom of another disease or condition.. Bleeding from esophageal ulcers may cause iron deficiency anemia.It is often associated with chronic GERD.

Gastroesophageal reflux disease is the abnormal backflow of stomach acid and juices into the esophagus. Gastroesophageal reflux disease occurs in infants too. Infants who have gastroesophageal reflux disease may not gain weight, may have respiratory problems and may develop more slowly.

This backflow occurs when the valve between the lower end of the esophagus and the stomach does not close tightly enough.

72 year-old woman with scleroderma and associated chronic reflux, with severe distal esophagitis, stricture formation and extensive, deep ulceration.

Illustrated examplesIllustrated examples::

83 year-old man with dysphagia, dyspepsia. Endoscopy revealed twin "kissing" ulcers just above a lower esophageal stricture through which the endoscope would not pass until after gentle balloon dilation.

70 years old woman with hematemesis, Endoscopy demonstrated a long, deep benign distal esophageal ulcer.

NoteNote:: More than half of patients with AIDS will develop esophageal disease. The most common pathogenic organisms causing esophageal symptoms in HIV-infected patients include Candida, herpes simplex virus, and cytomegalovirus, but bacterial infections with Mycobacterium tuberculosis and parasitic infections with Leishmania protozoa have also been reported

Zollinger-Ellison syndromeZollinger-Ellison syndrome:: A large amount of excess acid is produced in response to the overproduction of the hormone gastrin, which in turn is caused by tumors on the pancreas or duodenum. These tumors are usually malignant, must be removed and acid production suppressed to relieve the recurrence of the ulcers.

Curling's Curling's ulcerulcer

Curling's ulcer is an acute peptic ulcer of the duodenum resulting as a complication from severe burns when reduced plasma volume leads to sloughing of the gastric mucosa. These stress ulcers were once a common complication of serious burns, especially common in child burn victims. They result in perforation and hemorrhage and had correspondingly high mortality rates.

Diagnosis or Investigations:CBC: complete blood count to detect anemia (bleeding from esophageal ulcers may cause iron deficiency anemia.)Fecal analysis because blood may be present in feces.Endoscopy is an exam that uses an endoscope, a thin, lighted tube with a tiny camera on the end. If an ulcer is bleeding, the doctor can use the endoscope to inject drugs that promote clotting or to guide a heat probe that cauterizes the ulcer.

Bleeding:As an ulcer erodes the muscles of stomach, or duodenal wall,

blood vessels may also be damaged,which causes the bleeding.

Over a period of time, the patient becomes anemic.

Can be treated endoscopically byLocating the ulcer &cauterizing the BV

With heating device or injected with material

to stop bleeding.

Perforation:Sometimes,

ulcer eats a hole in wall of the stomach, or duodenum.

Bacteria & partially digested foodcan spill through the opening

into the sterile abdominal Cavity(paritonium).This causes paritonitis,an inflammation of the

abdominal cavity & wall.Immediate hospitalization

and surgery is usually required.

ComplicationsComplications

Narrowing and obstruction:

Ulcers located at the end of stomach where the duodenum is attached

may cause swelling & scarringthis can narrow or close the

intestinal opening& can prevent food from leaving stomach

& entering the SI.As a result,a person may vomit the contents of the stomach.

Endoscopic balloon dilation May be done.

Barium X-ray examination (less expensive method of diagnosing peptic ulcer).But X-ray examination does have some limitations: It is unable to define mucosal disease ex: gastritis.It is not definitive in differentiating benign from malignant gastric ulcer.It cannot delineate superficial, subacute gastric or duodenal erosions.It cannot define complete healing of an ulcer.Furthermore, as an ulcer heals, the surrounding tissue, especially in the duodenum, becomes scarred and deformed and radiologic assessment of activity of the ulcer becomes more difficult.

Receptors present on the cell Receptors present on the cell membrane of parietal cells in stomach:membrane of parietal cells in stomach:

M1 Receptors: stimulated by acetylcholine secreted from the para-sympathetic nerve endings (vagus nerve).

Gastrin Receptors: stimulated by gastrin hormone from mucosa of stomach and duodenum into the blood. presence of food causes distention of the stomach this will cause stimulation of mucosa so gastrin hormone increases in blood and parietal cells increase the secretion of HCl.

H2 Receptors: stimulated by histamine secreted from mast cells in stomach.

MedicationMedication

SurgerySurgery

Changing Changing Life styleLife style

Treatment

To relieve the symptoms

(pain, vomiting, blood loss).

To prevent recurrence of

ulcer bymaintenance

therapy.

To prevent complications

of ulcer.

To promote healing of ulcer.

To eliminate the sourceof problem.

Aims of

treatment

DRUGS

Anti secretory Drugs:

they reduce gastric

acid secretion

Cytoprotective drugs having

mucosal Protective properties

H2 blocker:first line

of treatment of

peptic ulcer

Anti-muscarinic

drugs

Protonpump

inhibitors

Sucralfates Bi-chelates

Misoprostol Antacids

Antibiotics:To kill H. Pylori

DRUGS

Anti secretory Drugs:

they reduce gastric

acid secretion

H2 blocker:first line

of treatment of

peptic ulcer

Anti-muscarinic

drugs

Protonpump

inhibitors

H2 -AntihistamineH2 -AntihistamineMode of action :These are competitive antagonists with histamine on H2 receptors found on the parietal cells of the stomach so they can reduce gastric acid secretion.They are given as first line of treatment for 4 weeks then the patient is examined to see if ulcer healed. If ulcer is healed so the patient moves to lower dosage regimen such as maintenance therapy.If ulcer is not healed so shift to another line of treatment.Side effects: constipation, diarrhea, headache, stomach cramps.

H2 antihistaminics

Ranitidine Cimetidene

Nazitidine Famotidine

Axid(amp+cap)

Apo-famotidine

Apo-cimetidine CimetrilApo-ranitidine Ranicux

Rantag Zantac

Gastrodomina Pepcid

Famodar

Neutronorm

Ranitidine

Nazitidine

Proton Pump InhibitorsProton Pump InhibitorsMode of action:They irreversibly inhibit H+ pump or H+/K+ ATPase which is an enzyme in the cell membrane of oxyntic or parietal cells, they block the final step for HCl secretion.Regular use of these can cause achlorohydria because they act on HCl formation not on receptors that increase HCl secretion. They are the most potent anti-secretory drugs.Side effects: constipation, diarrhea, colic, nausea.

P. pumpinhibitor

Rabeprazole Pantoprazole

Omeprazole lansoprazol

Gastrimut Risek

Epirazole Gastrazole

Omepral Oprazole

Pariet Inipomp

Takepron Lanzor

Ulstop Zimor

Esomeprazole

Nexium

Rabec

Lanzomide

Omedar Omizec

Omiz

Rabeprazole

Omeprazole

Omeprazole

Esomeprazole

Antimuscarinic DrugsAntimuscarinic Drugs

Mechanism of action:they are selective M1 antagonists.

They are used in combination with H2 blocker because histamine is the main mediator for HCl secretion.

DRUGS

Cytoprotective drugs having

mucosal Protective properties

Sucralfates Bi-chelates

Misoprostol Antacids

SucralfateSucralfateit is the aluminum salt of sucrose octasulfate i.e. sulfated sucrose + Aluminum hydroxide.Trade name:sucrate gel (sucralfate oral gel)Mode of action: It has a mucosal protective action, it increases mucus production, increases bicarbonate, and increases prostaglandin synthesis. The drug prevents the negative effects of smoking on ulcer healing so it is the first line treatment in case of smokers in combination with antisecretory drugs(H2 blockers). Moreover, in the acid medium of the stomach, it forms a gel that adheres to the surface of ulcer and provides physical protection. Given orally, it has minimum systemic absorption and it's excreted in feces. Side effects: • constipation due to aluminum• 3 to 5% of aluminum salt can be absorbed and this will cause aluminium toxicity, so it is not used as maintenance therapy.

Bismuth chelatesBismuth chelates::Mode of action:they have mucosal protective activity increase prostaglandins increase bicarbonate increase mucus production

They have toxic effect on Helicobacter pylori (bactericidal) can be used as first line treatment with H2 blocker if helicobacter infection is positive.

Side effects: blackening of the tongue, teeth, and stools.

N.B: Certain % of bismuth is absorbed so this causes bismuth toxicity so it is not used for maintenance therapy.

Misoprostol (Cytotec)Misoprostol (Cytotec)Mechanism of action: It causes mucosal protection by:•Increasing mucus and bicarbonate production.•Decreasing gastric HCl secretion

Uses: It is only used for prevention of NSAID_induced ulceration in patients with high risk•Elderly•Smokers•Patients with history of gastric bleeding. When NSAIDs are stopped, discontinue misoprostol.

Side effects:•Gastro intestinal disturbances (vomiting, diarrhea, colic) due to prostaglandin induced smooth muscle contraction.•Gynecological disturbances (spotting,dysmennorhea).•Uterine contractions (contra-indicated in pregnancy because they cause abortion).

AntacidsAntacids

Mode of action: used for symptomatic relief. They act via neutralization of the gastric HCl.

AntacidAdverse rxnAl hydroxideconstipationMg(hydroxide or trisilicate)

diarrhea

So a mixture of aluminum and magnesium is used in combination with H2 blocker and to relieve the symptoms of hyperacidity.

Unsuitable antacidsUnsuitable antacidsAntacidUnsuitable due toSodium bicarbonate salt production of CO2 that

stimulates gastrin secretion so increases HCl and produces flatulence &its rapidly absorbed and cause metabolic alkalosis.

Calcium carbonate production ofCO2 and CaCl2 that causes hypercalcemia.

DRUGS

Antibiotics:To kill H. Pylori

AntibioticsAntibiotics H. pylori can be very difficult to completely eradicate. Treatment requires a combination of several antibiotics, sometimes in combination with a proton-pump inhibitor, H2 blockers or Bi-chelate. Without such treatment there is an eighty percent chance the ulcer will reoccur within one year. Eradication of H. pylori prevents the return of ulcers (a major problem with all other ulcer treatment options) Elimination of this bacteria may also decrease the risk of developing gastric cancer in the future. An effective combination would be Amoxicillin + Metronidazole + Pantoprazole.

Surgery:Surgery may be necessary if you have bleeding, a perforation, or an obstruction.

Surgical options include the following: Endoscopic surgery Vagotomy and drainage Pyloroplasty Gastroduodenostomy GastrojejunostomyHighly elective vagotomyVagotomy with antrectomy

Dietary changes that may be helpful:Dietary changes that may be helpful: SUGARSUGAR & SALT& SALT People with ulcers have been reported to eat more sugar than people without ulcers.Salt is a stomach and intestinal irritant. Higher intakes of salt have been linked to higher risk of stomach ulcer. As a result of these reports, some doctors suggest that people with ulcers should restrict the use of both sugar and salt, although the benefit of such dietary changes remains unknown.

Many years ago, researchers reported that cabbage Juice accelerated healing of peptic ulcers. Drinking a quart of cabbage juice per day was necessary for symptom relief in some reports.

Carrot juice may be added to improve the flavor.

Advice For Duodenal ulcer PatientsAdvice For Duodenal ulcer Patients

Fiber slows the movement of food and

acidic fluid from the stomach to the intestines, which should help those with duodenal ulcer.

Lifestyle changes that may be helpful:Lifestyle changes that may be helpful:

Aspirin and related drugs (NSAID), alcohol, coffee, and tea can interfere with the healing of peptic ulcers. Smoking is also known to slow ulcer healing. Whether or not an ulcer is caused by infection, people with peptic ulcer should avoid use of these substances.

Nutritional supplements that may be Nutritional supplements that may be helpful:helpful:

Vitamin A is needed to heal the linings (m.m) of the stomach and intestines. High dose should not be taken by a pregnant woman, by a woman who could become pregnant, or by anyone else without careful supervision from a doctor. The effect of lower amounts of vitamin A has not been studied in people with peptic ulcer.

ZINCZINC

Zinc is also needed for the repair of damaged tissue and has protected against stomach ulceration in animal studies.

Copper must be taken to avoid copper deficiency that would be induced by the zinc supplementation.

GlutamineGlutamine

Glutamine, an amino acid, is the principal source of energy for cells that line the small intestine and stomach. Glutamine has also prevented stress ulcers triggered by severe burns in another preliminary study.

VITAMIN CVITAMIN C

Little is known about the effects of Vitamin C in peptic ulcer cases.Vitamin C may also help eradicate H. pylori in people with gastritis. Vitamin C may one day prove to have a therapeutic effect for people with peptic ulcer; however, further research in this area is needed.

Herbs that may be helpful:

Licorice root has a long history of use for soothing inflamed and injured mucous membranes in the digestive tract. Licorice may protect the stomach and duodenum by increasing production of mucin. Flavonoids in licorice may also inhibit growth of H. pylori.

CHAMOMILECHAMOMILEChamomile has a soothing effect on inflamed and irritated mucous membranes. It is also high in the flavonoid apigenin, another flavonoid that has inhibited growth of H. pylori.Chamomile is also available in capsules.Calendula is another plant with anti-inflammatory and healing activities that can be used as part of a traditional medicine approach to peptic ulcers. The same amount as chamomile can be used.

Marshmallow is high in mucilage. High-mucilage-containing herbs have a long history of use for irritated or inflamed mucous membranes in the digestive system.

GARLICGARLIC

Garlic has been reported to have anti-Helicobacter activity.

PreventionsPreventions::To decrease risk of ulcer from H. pylori infection: Wash your hands after using the bathroom and before eating or preparing food.

Drink water from a safe source.

Don’t smoke. Cigarette, smoking increases the chances of getting an ulcer.

PreventionsPreventions::

To decrease the risk of ulcer from NSAIDs:

Use other drugs when possible for managing pain. Take the lowest possible dose. Do not take longer than needed. Do not drink alcohol while taking the drugs.