PEPTIC ULCER DISEASE (PUD)

Peptic ulcers are open sores that develop on the inside lining (mucosal wall) of the esophagus, stomach and the upper portion of the small intestine. The digestive tract is lined with a mucous layer that normally protects against acid but if the amount of acid in the digestive tract is in excess or the amount of mucus is decreased, an ulcer can develop. Peptic ulcer disease happens when the acid in the digestive tract eats away at the inner surface of the stomach or small intestine. The acid can cause a painful open sore that may bleed.

Types of Peptic Ulcer

This depends on the location affected and this include:

  1. Gastric Ulcers: This occurs on the inside of the stomach.
  2. Esophageal Ulcers: This occurs in the lining at the junction of the esophagus and stomach.
  3. Duodenal Ulcers: This occurs on the inside of the upper portion of the small intestine (duodenum).

Causes of Peptic Ulcer

The causes of peptic ulcer disease include:

  1. Bacteria: The most common cause of peptic ulcer is infection with the bacterium Helicobacter pylori (H. pylori).
  2. Drugs: Long term use of nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Advil, Motrin IB, etc.), Analgesics, and naproxen sodium (Aleve). They can alter gastric secretions.
  3. Stress ulceration due to burns shock severe sepsis
  4. Excessive smoking
  5. Alcohol ingestion
  6. Familial tendency

Signs and Symptoms of Peptic Ulcer Disease

  1. Burning stomach pain or upper abdominal pain
  2. Tenderness of the abdomen
  3. Nausea and Vomiting
  4. Weight loss
  5. Anorexia
  6. Epigastric distention: Feeling of fullness, bloating or belching
  7. Dark blood in stools, or stools that are black or tarry
  8. Intolerance to fatty foods
  9. Heartburn

Diagnosis of Peptic Ulcer Disease

To diagnose peptic ulcer, history taking and physical examination are done. To confirm peptic ulcer diagnosis, the following tests may be carried out:

  1. Helicobacter pylori test: The test is carried out to determine whether the bacterium is present in the body. Helicobacter pylori test can be carried out using either a blood, stool or breath test. For the breath test which is the most accurate, the client drink or eat something that contains radioactive carbon e.g., Brazil nuts and Bananas. Helicobacter pylori breaks down the substance in the stomach. The client is later asked to exhale into a bag, which is then sealed. The breath sample of an infected person will contain the radioactive carbon in the form of carbon dioxide.
  2. Endoscopy (esophagogastriduodenoscopy): This procedure is carried out to locate the ulcer. To carry out the procedure, a hollow tube equipped with a lens (endoscope) is put down the client’s throat and into the esophagus, stomach and small intestine. If an ulcer is suspected or detected, a part of the tissue (biopsy) may be removed for examination to confirm the presence of the bacteria.
  3. Upper Gastrointestinal Series: For this test, a barium swallow may be recommended. During the X-ray, a white liquid (containing barium) is swallowed. This coats the digestive tract, and images of the esophagus, stomach and small intestine are produced. This test makes an ulcer more visible.
  4. Gastric Secretion Analysis: This is used to analyses gastric secretions levels and acidity.
  5. Stool for Occult Blood: This reveals bleeding if there is ulcer.

Medical Management of Peptic Ulcer Disease

The treatment of peptic ulcer depends on the cause. The medical treatment of this condition includes:

  1. Antibiotics: If Helicobacter pylori is found in the digestive tract, the doctor may recommend a combination of antibiotics to kill the bacterium. These may include amoxicillin (Amoxil), clarithromycin (Biaxin), metronidazole (Flagyl), tinidazole (Tindamax), tetracycline and levofloxacin.
  2. Proton pump inhibitors: These medications block acid production. They reduce stomach acid by blocking the action of the parts of cells that produce acid. These drugs also promote the healing of ulcers. These drugs include omeprazole (Prilosec), lansoprazole (Prevacid), rabeprazole (Aciphex), esomeprazole (Nexium) and pantoprazole (Protonix).
  3. Medications to reduce acid production: Histamine (H2) receptor blockers or antagonists inhibit acid secretion by blocking the action of histamine on the histamine receptors of the parietal cells in the stomach. The acid released into your digestive tract is reduced which relieves ulcer pain and promotes healing. Examples are famotidine (Pepcid AC), cimetidine (Tagamet HB) and nizatidine (Axid AR).
  4. Antacids:  Antacids that neutralizes stomach acid may be prescribed. The antacids produce symptomatic relief, facilitate ulcer healing and prevent further ulceration. They are administered after meals and at bed time. Examples are aluminium hydroxide, calcium carbonate, magnesium hydroxide, etc.
  5. Medications that protect the lining of the stomach and small intestine: Cytoprotective agents may be prescribed to help protect the tissues that lines the stomach and small intestine. Examples are sucralfate (Carafate) and misoprostol (Cytotec).
  6. Anti-cholinergic drugs: The drugs decrease gastric acid secretion thereby reducing pain e.g., pro-banthine, atropine sulphate, and glycopyrrolate.

Most peptic ulcer heal with prompt medical intervention but there are peptic ulcers that do not heal with medical treatment. They are called refractory ulcers. The causes of refractory ulcer may include:

  1. Noncompliance to medical prescription.
  2. Resistance of Helicobacter pylori to antibiotics
  3. Constant use of tobacco
  4. Regular use of pain relievers such as NSAIDs
  5. Some conditions or diseases that causes extreme overproduction of stomach acid, such as Zollinger-Ellison syndrome
  6. Stomach cancer
  7. Diseases that can cause ulcer-like sores in the stomach and small intestine, such as Crohn’s disease

Treatment of refractory ulcers include managing factors that interferes with healing.

Surgical Management of Peptic Ulcer Disease

Surgical interventions are usually recommended in cases of complications. They include:

  1. Vagotomy: This is cutting of the branches of the vagus nerve to inhibit gastric acid secretion thereby decreasing acid-secreting stimulus to gastric cells.
  2. Pyloroplasty: This is widening the pyloric valve between the stomach and the duodenum to relieve obstruction and facilitate gastric emptying or tightening to reduce duodenal reflux into the stomach.
  3. Gastric Resection Subtotal Gastrectomy: This is the removal of the distal part of the stomach with surgical joining to the duodenum or removal of the part of the stomach and the duodenum with surgical joining to the jejunum. Gastric resection is indicated in complications of peptic ulcer.

Prevention of Peptic Ulcer Disease

To reduce the chances of developing peptic ulcer disease, the following are recommended:

  1. Prevention of infection by frequently washing of hands with soap and water and by eating foods that have been cooked completely.
  2. Take medications with caution. Follow medical prescriptions before intake of NSAIDs and analgesics.
  3. Avoid alcohol consumption
  4. Quit smoking

Complications of Peptic Ulcer Disease

Peptic ulcer if left untreated, can lead to:

  1. Hemorrhage
  2. Perforation (a hole in the stomach hole)
  3. Penetration
  4. Pyloric obstruction
  5. Infection (Peritonitis)
  6. Gastric cancer

 

 

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