The stomach is one of the most important organs in our body and it is the most dilated organ found in the digestive tract. It is preceded by the esophagus and followed by the small intestine. It dilates and allows the capacity to hold food and it can be divided into four main regions as Cardia, Fundus, Body, and Pylorus. Peptic ulcer disease can be defined as a condition that affects these two organs including the stomach and duodenum. Duodenum is the first part of the small intestine. And it helps to further digest food coming from the stomach to be digested and it also absorbs,
- Nutrients such as vitamins, minerals, carbohydrates, fats, proteins
- Water from food.
The wall of both the stomach and duodenum consists of many layers, including,
- Mucosal Layer
- Submucosal Layer
- Muscular Layer
- Subserosal Layer
- Serosal Layer
Among them, the mucosal layer can be further divided into three layers called, Epithelium, Lamina Propria, and Muscularis Mucosa.
Peptic ulcer disease is caused due to a break in the superficial epithelium cells that penetrate down the muscularis mucosa of either stomach or the duodenum. These ulcers have a base; that is fibrous and has an increase in inflammatory cells. Gastric erosions are quite different from peptic ulcers as they are only observed in the mucosal layer. Also they don’t extend up to muscularis mucosa. Although these ulcers can be found anywhere in these two organs, more common places for them to occur have been identified. In the stomach, the area near the lesser curvature and in the duodenum the area near the duodenal cap and surrounding mucosa are involved most commonly.
Epidemiology
- Duodenal ulcers are found to be two to three times more commoner than gastric ulcers.
- The incidence of ulcers is declining among the younger population and is increasing among the adult population.
- Among men and women, it is increasingly reported among elderly women than men.
- Also, a geographical variation of the causes of peptic ulcer disease is observed. Peptic ulcers due to Helicobacter pylori infection are found more frequently in people in developing countries while peptic ulcers due to NSAIDs are found more frequently in developed countries.
Causes for Peptic Ulcer
You need to identify how these ulcers are caused to identify the causative factors. These ulcers are caused due to the damage done by the acid of your digestive tract. These acids digest the inner surface of the stomach and duodenum. Although the mucous layer acts as a barrier to protect the gastrointestinal tract against the acids secreted by it, when the amount of acids secreted is increased or if the amount of mucous is decreased you can get peptic ulcers. Factors that can cause this scenario can be listed below.
- A bacterial organism that lives in the mucous layer called Helicobacter pylori can cause increased inflammation of the inner layer of the stomach causing ulcers. This organism can spread from person to person through close contact which includes kissing or sharing the same food items and also through food and water.
- Some drugs we take to relieve pain known as ‘Non-steroid anti-inflammatory drugs’ (NSAIDs) can cause thinning of the protective mucosal layer that covers the gastrointestinal tract making it predisposed to get ulcers. Such drugs include ibuprofen, naproxen sodium, ketoprofen, and others. They do not include acetaminophen.
- Also, consumption of certain other medications such as steroids, anticoagulants, low-dose aspirin, selective serotonin reuptake inhibitors (SSRIs), alendronate (Fosamax), and risedronate (Actonel), along with the above-mentioned NSAIDs, can greatly increase the chance of developing ulcers.
- Drinking too much alcohol and consuming lots of tobacco products.
- Radiation therapy.
- Stomach cancers
Risk Factors of Peptic Ulcer
- Smoking can increase the risk of peptic ulcers, especially among people who are infected with H.pylori.
- Consumption of alcohol frequently can increase the amount of acids produced by the stomach and it can irritate the lining layers of the stomach.
- Consuming high amounts of spicy and chilly food.
- An increased amount of stress due to social or other factors can also increase your risk to get peptic ulcers.
- Having relatives in the family who have had peptic ulcer disease previously.
- Being female
- Being sixty-five years or older than that
Clinical Features
- Recurrent, burning-type pain of the upper, central part of the abdomen is the characteristic presentation of patients with peptic ulcer disease. Normally if you have this disease, you will be going to the doctor and will be pointing one finger towards the upper, central area of the abdomen as the site of pain which highly suggests peptic ulcers. Can also be called heartburn.
- Pain can be associated with ingestion of food or not. But the pain due to duodenal ulcers most often occurs at night and it becomes worse when you are hungry.
- This pain can be easily relieved by the consumption of antacids.
- Nausea and vomiting can also be present along with the pain. Vomiting is infrequent but it can relieve the pain.
- Loss of appetite and loss of weight can also present, especially with gastric ulcers.
- If the pain is getting severe, persistent, or is associated with back pain it can be suggestive of perforations or complications of peptic ulcers.
- A feeling of fullness and abdominal bloating
- Intolerance of fatty food
- Dark-colored stools as in black or tarry colored
- A feeling of fainting and troubled breathing
- What are the Dangerous Symptoms which You Must Seek for Urgent Medical Attention
- Sudden. Sharp abdominal pain
- Fainting, excessive sweating, or confusion which can be due to being in shock because of severe internal bleeding
- Blood in vomitus or stools
- Abdomen that is hard to palpate and the abdominal pain that gets worsens with movements but improves with lying completely still
Complications of Peptic Ulcer
If you leave ulcers for a prolonged time without treating them, you can get complications as below.
- Perforation – Ulcers can get complicated and form holes in the lining of your stomach or duodenum which can also lead to severe infections. This condition can get presented with symptoms such as sudden, severe abdominal pain.
- Internal bleeding can cause severe bleeding inside your abdomen which can give rise to symptoms such as lightheadedness, dizziness, and tarry or black color stools.
- Scar tissues can develop in the process of healing these ulcers which can create strictures or narrowing of the gastrointestinal tract which can make it hard for food to pass through the digestive tract. This condition can be presented with symptoms such as vomiting, weight loss, or reduced bowel output with abdominal distension.
Diagnosis of Peptic Ulcer
Initially, your doctor will ask for features suggestive of peptic ulcer disease in the history of your presentation. The doctor will examine you clinically for the above signs and symptoms. If it is suggestive of peptic ulcer disease through the history and examination you will be next directed towards specific investigations.
Investigations to Diagnose Helicobacter Pylori Infection (H.Pylori)
- Serological tests to detect immunoglobulin G antibodies.
- The urea breath test measures the amount of carbon dioxide in your breath after letting you ingest C-urea. As the preparation for this test, you must avoid taking antibiotics for four weeks and proton pump inhibitors for two weeks before the intervention.
- A stool antigen test is used to diagnose H. pylori infection and to monitor the efficacy of eradication therapy given. You must avoid taking proton pump inhibitor drugs two weeks after this test as well.
- Invasive investigations using endoscopy as biopsies and histological analysis are also used. During this procedure, your doctor will insert a long tube that has a small camera at the end of it called an endoscopy down your throat and into the stomach and duodenum to examine the area for ulcers or any complications. In this investigation, your doctor will get small tissue samples as well for further investigations such as histology and cultures.
For patients who are not responding to treatment, cultures can also be done. Older patients over 55 years of age must be undergone endoscopic investigations to exclude the risk of carcinoma. Also, all the patients presenting with symptoms called alarming symptoms including loss of weight, loss of appetite, persistent vomiting, vomiting of blood, stools stained of blood, etc should undergo endoscopic investigations to identify any complications and treat them appropriately.
Treatment for Peptic Ulcer
Pharmacological Treatment
Pharmacological management is the mainstay of therapy for peptic ulcer disease
Ulcers caused by Helicobacter Pylori
A therapy called eradication therapy is given to you which includes three types of medications that are effective to eradicate bacterial organisms. The most common regime includes Omeprazole 20mg, Clarithromycin 250mg, and Metronidazole 500mg given for a duration of seven to fourteen days. It is important to not miss or skip getting drugs as it can reduce the efficacy of your treatment.
Ulcers caused due to NSAIDs
- Should stop the ingestion of NSAIDs as soon as possible. Next, you will be prescribed a proton pumps inhibitor such as Omeprazole or Esomeprazole. This treatment will be combined with the above-mentioned eradication therapy if an associated H.Pylori infection is also diagnosed.
- If you are having a disease such as severe arthritis and you can’t be discontinued NSAIDs, your doctor will continue you on an NSAID with low gastrointestinal side effects at the lowest dose possible. This must be done only under the advice of an experienced medical doctor.
- If you are a patient who is having NSAIDs for a prolonged period and if you are having other risk factors such as increased age or a history of peptic ulcers, you will be given drugs to protect you from developing peptic ulcer disease in the future. Such drugs are misoprostol or proton pump inhibitors.
Surgical Treatment
If you are having complications such as recurrent bleeding or perforations due to peptic ulcer disease you will be suggested to undergo surgical treatment. This surgical treatment includes complex procedures such as gastrectomy or vagotomy. But these procedures can have long-term complications such as,
- Recurrent ulcers.
- Several abdominal symptoms such as nausea, abdominal distension, faintness.
- Palpitations most commonly after gastrectomy procedures, diarrhea, and nutritional complications such as iron deficiency, folate deficiency, vitamin B12 deficiency, and loss of weight.
Life Style Modification
How to Prevent Yourself from Getting the Infection?
- It is important to keep in mind that H.pylori infection can spread from person to person or through food and water. So, you must be cautious to protect yourself from getting the infection through frequent washing of hands with soap and water, eating food that has been cooked completely under good hygiene, drinking boiled water, and avoiding tap water as much as possible.
- You must avoid getting NSAID-type painkillers regularly which can increase your risk of getting peptic ulcers. And if you need to get them you must get them with meals which will reduce your risk. Also, rather than getting over-the-counter painkillers, you must meet your doctor and discuss getting a painkiller that has the lowest gastrointestinal side effects and must get in the lowest dose.
- If you are having symptoms suggestive of peptic ulcer disease such as heartburn or abdominal pain, do not ignore it for a long time. Meet your doctor as soon as possible and get treated as you can get life-threatening complications by leaving peptic ulcers untreated for a long time.
- You must avoid consuming alcohol and getting tobacco products as much as possible.
- Having a balanced diet rich with all the nutrients required for good health is important.
Daily Exercises
- Engaging in regular exercise and maintaining a good weight with a BMI level in the healthy range.
- Getting an adequate time of at least six hours a day is important to reduce stress. Also scheduling your work according to a timetable will make you time to relax.
- Engaging in mind-relaxing activities such as hobbies, sports, meditation, or other activities can reduce your stress level and make your mind calm which will reduce the formation of peptic ulcers due to stress-induced increased gastric acid secretion.
- There are misinterpretations as coffee can induce the formation of peptic ulcers. But it had never been proven through scientifical studies.
References
- Bailey and Love’s Short Practice of Surgery- 27th Edition
- Kumar and Clerk’s Clinical Medicine -8th Edition- Parveen Kumar, Michael Clark
- Oxford Handbook of Clinical Medicine – 10th Edition
- Browse’s Introduction to the Symptoms and Signs of Surgical Disease – 4th Edition – Norman L. Browse, John Black, Kevin G. Burnand and William E.G. Thomas
- Image by wavebreakmedia_micro on Freepik
- Image by jcomp on Freepik
