PEPTIC ULCER DISEASE

Pukar K.CKathmandu University School of Medical Sciences

NormalEsophagus &

Stomach

DEFINITIONS Ulcer

Breach in the mucosa of the GI tract that extends through the muscularis mucosa into submucosa or deeper

ErosionEpithelial disruption without breach of the

muscularis mucosa Peptic Ulcer disease

Circumscribed ulcer that occurs in any part of the GI tract due to the aggressive action of acid and peptic juices.

SITES OF ULCERS First part of

Duodenum Lesser curve of

stomach Stoma following

gastric surgery Oesophagus Gastric mucosa

within Meckel’s Diverticulum

ETIOLOGY Helicobacter pylori infection Chronic NSAIDs and Corticosteroids use Cigarette smoking Alcohol consumption Zolinger-Ellison syndrome Hyperparathyroidism and chronic renal

failure

PATHOGENESIS

Zollinger- Ellison syndrome Uncontrolled secretion of gastrin by tumor

resulting massive acid production NSAIDs use

Direct chemical irritation Suppressing prostaglandin synthesis

Cigarette smoking Impaired mucosal blood flow and healing

Hyperthyroidism and chronic renal failure Hypercalcemia induced excessive gastrin

secretion

H. PYLORI Flagella Urease

Generates ammonia from endogenous urea and elevates pH

Adhesins Enhance bacterial adherance to surface cells

Toxins CagA gene

H. PYLORI

ETIOLOGIC FACTORS OF PUD

Features Gastric ulcers Duodenal ulcers

Incidence Less common More common

Common Location Antrum, lesser cuvature

Anterior wall*, 1st part

Age group Middle age Middle or old age

Male: Female ratio 1:1 4:1

Association with H. Pylori

65% 85%-100%

Level of gastric acid secretion

Mostly normal Mostly increased

Malignancy Common Rare

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

TYPES OF GASTRIC ULCERDAINTREE JOHNSON

•Type IIn the antrum, near lesser curvatureNormal acid level•Type IICombined gastric and duodenal ulcerHigh acid level•Type IIIPrepyloricHigh acid level•Type IVUlcer in the proximal stomach and CardiaNormal acid level

55% 25%

15% 5%

FEW MORE ULCERS!!! Stress ulcer

In association with shock, sepsis or severe trauma

Curling ulcer In association with severe burns or trauma

Cushing’s ulcer In patients with intracranial disease oor after

neurosurgery

CLINICAL PRESENTATION Symptoms

Pain Epigastric region, burning or aching type May radiate to back

Heartburn, Nausea, vomiting, bloating, belching, water-brash

Alteration in weight Haematemesis or Maelena presents as anemia Periodicity of symptoms

Significant past history Clinical examination

Tender epigastrium Features of complication, if present

Gastric Ulcer Duodenal Ulcer

Pain increased after food intake Pain relieved after food intake

Periodicity less common Periodicity more common

Haematemesis more common Melaena more common

Weight loss common Weight gain occurs

Equal in both sexes More in males

INVESTIGATIONS Esophagogastrodeodenoscopy (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 FOLDS

Converging folds

Margin Regular

Floor Granulation tissue in floor

Edges NOT everted ,punched

Surrounding Area

Normal

Size and Extent

Small deep up to muscle layer

MALIGNANT GASTRIC ULCERMUCOSAL FOLDS

Effacing Mucosal folds

Margin Irregular margin

Floor Necrotic Slough in the floor

Edges Everted Edges

Surrounding Area

Shows nodules, ulcers and irregularities

Size and Extent

Large and Deep

BARIUM SWALLOW Outpouching of ulcer crater beyond the gastric

contour (exoluminal) Overhanging mucosa at the margins of a benign

gastric ulcer, project inwards towards the ulcer Regular/ Round Margin of the Ulcer Crater Converging mucosal folds towards the base of

ulcer STOMACH SPOKE WHEEL PATTERN HAMPTON LINE: A thin millimetric radiolucent

line seen at the neck of a gastric ulcer in barium studies

Deformed or absent duodenal cap

HAMPTON LINE: A thin millimetric radiolucent line seen at the neck of a gastric ulcer in barium studies

STOMACH SPOKE` WHEEL PATTERN

TESTS FOR H. PYLORI Noninvasive tests

Serum or whole blood antibody testsImmunoglobin G (IgG)Urea breath test

Patient drinks a carbon-enriched urea solution Excreted carbon dioxide is then measured

Invasive tests Biopsy of stomach Rapid urease test

COMPLICATION

•Hemorrhage•Perforation•Penetration•Narrowing and obstruction

HEMORRHAGE Blood vessels damaged as

ulcer erodes into the muscles of stomach or duodenal wall

Coffee ground vomitus or occult blood in tarry stools

Posterior wall duodenal ulcerArteries involved

GASTRIC ULCER erode LEFT GASTRIC VESSELS and SPLENIC VESSELS

DUODENAL ULCER erodes GASTRODUODENAL artery

PERFORATION Can erode through the entire wall Spillage of gastric/duodenal content and

bacteria into peritoneum leading to peritonitis

Mostly associated with NSAIDs ulcers Anterior wall duodenal ulcer

PENETRATION Ulcers 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 OBSTRUCTION Hour glass contracture

Cicatricial contracture of lesser curvature ulcer, dividing the stomach in two compartments

Teapot deformity Cicatrisation and shortening of lesser curve

Pyloric stenosis Scarring and cicatrisation of first part of

duodenum Persistent vomiting

MANAGEMENT Non-pharmacological Pharmacological Surgical

PHARMACOLOGICAL MANAGEMENT Provide pain relief

Antacids and mucosa protectors Eradicate H. pylori infection

Two antibiotics and one acid suppressor Heal ulcer

Eradicate infection Protect until ulcer heals

Prevent recurrence Decrease high acid stimulating foods in susceptible

people Avoid use of potential ulcer causing drugs Stop smoking

AIM

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 DRUGS Proton Pump Inhibitors

Suppress acid production

H2-Receptor Antagonists Block histamine-stimulated

gastric secretions

Antacids Neutralizes acid and

prevents formation of pepsin

Give 2 hours after meals and at bedtime

Prostaglandin Analogs Reduce gastric acid

and enhances mucosal resistance to injury

Mucosal barrier fortifiers Forms a protective

coat Sucralfate

MEDICAL TREATMENT

ERADICATION THERAPY Directed against H. pylori Regimens

Triple therapy for 2 weeks Omeprazole 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 daily

Clarithromycin 500 mg twice daily Amoxicillin 1 g twice daily

Quadruple therapy for 2 weeks Omeprazole 20 mg twice daily or pantoprazole 40 mg twice

daily or esomeprazole 40 mg daily or rabeprazole 20 mg daily

Bismuth subsalicylate 525 mg twice daily Metronidazole 250–500 mg three times daily Tetracycline 500 mg four times daily

The PPIs should be continued for 6 more weeks

SURGERY Indication

Complicated ulcers Not responding to medical treatment

TYPES OF SURGICAL PROCEDURES

2.Gastroenterostomyallows regurgitation of alkaline duodenal contents into the stomach• Gastrojejunostomy

1.Diversion of Acid Away from the duodenum• Billroth II

3.Reduce the secretory Potential of Stomach• Billroth I (gastric ulcer)• Truncal vagotomy and drainage• Highly selective vagotomy• Truncal vagotomy and

antrectomy

BILLROTH I GASTRECTOMY

Gastric ulcersDistal portion of the

stomach is mobilised and resected

The 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 jejunum

Recurrent ulceration is lowHigh Operative Mortality and Morbidity

SEQUELAE OF PEPTIC ULCER SURGERY Recurrent Ulceration

Small Stomach Syndrome

Bile Vomiting

Early and Late Dumping

Post Vagotomy Diarrhoea

Malignant Transformation

Nutritional Consequences

Gall Stones

OTHER TYPES OF ULCER NSAIDs induced ulcers

Antisecretory agents Stomal ulcers

Prolonged course of antisecretory agents Zollinger- Ellison syndrome

Proton pump inhibitors unless tumor can be managed by surgery

MANAGEMENT OF COMPLICATIONS