Peptic Ulcer Disease

Peptic Ulcer Disease

Pukar K.CKathmandu University School of Medical Sciences

NormalEsophagus & Stomach

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Definitions UlcerBreach in the mucosa of the GI tract that extends through the muscularis mucosa into submucosa or deeperErosionEpithelial disruption without breach of the muscularis mucosaPeptic Ulcer diseaseCircumscribed ulcer that occurs in any part of the GI tract due to the aggressive action of acid and peptic juices.

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Sites of UlcersFirst part of DuodenumLesser curve of stomachStoma following gastric surgeryOesophagus Gastric mucosa within Meckels Diverticulum

EtiologyHelicobacter pylori infectionChronic NSAIDs and Corticosteroids useCigarette smokingAlcohol consumptionZolinger-Ellison syndromeHyperparathyroidism and chronic renal failure

Pathogenesis

Zollinger- Ellison syndromeUncontrolled secretion of gastrin by tumor resulting massive acid productionNSAIDs useDirect chemical irritationSuppressing prostaglandin synthesisCigarette smokingImpaired mucosal blood flow and healing Hyperthyroidism and chronic renal failureHypercalcemia induced excessive gastrin secretion

H. PyloriFlagellaUreaseGenerates ammonia from endogenous urea and elevates pHAdhesinsEnhance bacterial adherance to surface cellsToxins CagA gene

H. Pylori

ETIOLOGIC FACTORS OF PUD

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Features Gastric ulcersDuodenal ulcersIncidenceLess commonMore commonCommon LocationAntrum, lesser cuvatureAnterior wall*, 1st partAge groupMiddle age Middle or old ageMale: Female ratio1:14:1Association with H. Pylori65%85%-100%Level of gastric acid secretionMostly normal Mostly increasedMalignancyCommonRare

*Kissing ulcers: Both anterior and posterior wall ulcer of duodenum

Types of Gastric UlcerDaintree Johnson

Type IIn the antrum, near lesser curvatureNormal acid levelType IICombined gastric and duodenal ulcerHigh acid levelType IIIPrepyloricHigh acid levelType IVUlcer in the proximal stomach and CardiaNormal acid level55%25%15%5%

Few more ulcers!!!Stress ulcerIn association with shock, sepsis or severe traumaCurling ulcerIn association with severe burns or traumaCushings ulcerIn patients with intracranial disease oor after neurosurgery

Clinical PresentationSymptomsPainEpigastric region, burning or aching typeMay radiate to backHeartburn, Nausea, vomiting, bloating, belching, water-brashAlteration in weightHaematemesis or Maelena presents as anemiaPeriodicity of symptomsSignificant past historyClinical examinationTender epigastriumFeatures of complication, if present

Gastric UlcerDuodenal UlcerPain increased after food intakePain relieved after food intakePeriodicity less commonPeriodicity more commonHaematemesis more commonMelaena more commonWeight loss commonWeight gain occursEqual in both sexesMore in males

InvestigationsEsophagogastrodeodenoscopy (EGD)

Barium swallow

Urea Breath Testing

EsophagogastrodeodenoscopyIt is fundamental that any gastric ulcer should be regarded as being Malignant, no matter how classically it resemble a benign gastric ulcer

Multiple biopsies should be taken, as many as 10 well targeted biopsies

Esophagogastrodeodenoscopy

Endoscopic procedure

Visualizes ulcer crater

Ability to take tissue biopsy to R/O cancer and diagnose H. pylori

Benign Gastric UlcerMUCOSAL FOLDSConverging foldsMarginRegularFloorGranulation tissue in floorEdgesNOT everted ,punched Surrounding Area NormalSize and ExtentSmall deep up to muscle layer

Malignant Gastric Ulcer

MUCOSAL FOLDSEffacing Mucosal foldsMarginIrregular marginFloorNecrotic Slough in the floorEdgesEverted Edges Surrounding Area Shows nodules, ulcers and irregularitiesSize and ExtentLarge and Deep

Barium swallowOutpouching of ulcer crater beyond the gastric contour (exoluminal)Overhanging mucosa at the margins of a benign gastric ulcer, project inwards towards the ulcerRegular/ Round Margin of the Ulcer CraterConverging mucosal folds towards the base of ulcerSTOMACH SPOKE WHEEL PATTERNHAMPTON LINE: A thin millimetric radiolucent line seen at the neck of agastric ulcerin barium studiesDeformed or absent duodenal cap

HAMPTON LINE: A thin millimetric radiolucent line seen at the neck of agastric ulcerin barium studiesSTOMACH SPOKE` WHEEL PATTERN

Tests for H. pyloriNoninvasive testsSerum or whole blood antibody testsImmunoglobin G (IgG)Urea breath testPatient drinks a carbon-enriched urea solutionExcreted carbon dioxide is then measuredInvasive testsBiopsy of stomach Rapid urease test

ComplicationHemorrhagePerforationPenetrationNarrowing and obstruction

Hemorrhage Blood vessels damaged as ulcer erodes into the muscles of stomach or duodenal wallCoffee ground vomitus or occult blood in tarry stoolsPosterior wall duodenal ulcerArteries involvedGASTRIC ULCER erode LEFT GASTRIC VESSELS and SPLENIC VESSELSDUODENAL ULCER erodes GASTRODUODENAL artery

Perforation Can erode through the entire wallSpillage of gastric/duodenal content and bacteria into peritoneum leading to peritonitisMostly associated with NSAIDs ulcersAnterior wall duodenal ulcer

penetrationUlcers may erode through the entire thickness of the gastric or duodenal wall into adjacent abdominal organs Can involve the pancreas, bile ducts, liver, and the small or large intestine. The pancreas is the most common site of penetration

Narrowing and obstructionHour glass contractureCicatricial contracture of lesser curvature ulcer, dividing the stomach in two compartmentsTeapot deformityCicatrisation and shortening of lesser curvePyloric stenosisScarring and cicatrisation of first part of duodenumPersistent vomiting

Management Non-pharmacologicalPharmacologicalSurgical

Pharmacological ManagementProvide pain reliefAntacids and mucosa protectorsEradicate H. pylori infectionTwo antibiotics and one acid suppressorHeal ulcerEradicate infectionProtect until ulcer healsPrevent recurrenceDecrease high acid stimulating foods in susceptible peopleAvoid use of potential ulcer causing drugsStop smokingAIM

Non-pharmacological

Avoid spicy food.Avoid Alcohol.Avoid Smoking.Avoid heavy meals.Encourage small frequent low caloric meals.Avoid ulcerating drugs e.g. NSAIDs, corticosteroids

Hyposecretory DrugsProton Pump InhibitorsSuppress acid production

H2-Receptor AntagonistsBlock histamine-stimulated gastric secretions

AntacidsNeutralizes acid and prevents formation of pepsin Give 2 hours after meals and at bedtime

Prostaglandin AnalogsReduce gastric acid and enhances mucosal resistance to injury

Mucosal barrier fortifiersForms a protective coatSucralfate

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Medical treatment

Eradication therapyDirected against H. pyloriRegimens Triple therapy for 2 weeksOmeprazole 20 mg twice daily or lansoprazole 30 mg twice daily or pantoprazole 40 mg twice daily or esomeprazole 40 mg daily or rabeprazole 20 mg dailyClarithromycin 500 mg twice daily Amoxicillin 1 g twice dailyQuadruple therapy for 2 weeksOmeprazole 20 mg twice daily or pantoprazole 40 mg twice daily or esomeprazole 40 mg daily or rabeprazole 20 mg dailyBismuth subsalicylate 525 mg twice dailyMetronidazole 250500 mg three times dailyTetracycline 500 mg four times daily The PPIs should be continued for 6 more weeks

SurgeryIndicationComplicated ulcersNot responding to medical treatment

Types of Surgical Procedures2.Gastroenterostomyallows regurgitation of alkaline duodenal contents into the stomachGastrojejunostomy

1.Diversion of Acid Away from the duodenumBillroth II

3.Reduce the secretory Potential of StomachBillroth I (gastric ulcer)Truncal vagotomy and drainageHighly selective vagotomyTruncal vagotomy and antrectomy

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Billroth I GastrectomyGastric ulcersDistal portion of the stomach is mobilised and resectedThe cut edge of the remnant is partially closed from Lesser Curvature aspect

Stoma at greater curvature aspectGastroduodenal anastomosis done

Billroth II GastrectomyThe lower portion of the stomach is removed along with the ulcer and the remainder is anastomosed to the jejunumRecurrent ulceration is lowHigh Operative Mortality and Morbidity

Sequelae of Peptic Ulcer SurgeryRecurrent Ulceration

Small Stomach Syndrome

Bile Vomiting

Early and Late DumpingPost Vagotomy Diarrhoea

Malignant Transformation

Nutritional Consequences

Gall Stones

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Other types of ulcerNSAIDs induced ulcersAntisecretory agentsStomal ulcersProlonged course of antisecretory agentsZollinger- Ellison syndromeProton pump inhibitors unless tumor can be managed by surgery

Management of complications