PEPTIC ULCER

PEPTIC ULCER
PUD - encompasses both gastric and duodenal
ulcers.
refers to a demonstrable ulcer, usually in the
duodenum or stomach.
ULCER - disruption of the mucosal integrity of the
stomach and/or duodenum leading to a local
defect or excavation due to active
inflammation.
- break in the mucosal surface >5mm depth to
the submucosa.
PREVALENCE
United States - 4 million individuals affected per year
12% in men and 10% in women
15,000 deaths per year of complicated PUD
 PEPTIC ULCER
DUODENAL ULCERS: GASTRIC ULCERS
Epidemiology:
estimated to occur in 6 to 15% occur later in life than
of the western population. duodenal lesions,with a peak
common in duodenal ulcer in those incidence reported in the 6th
from 3060 yr. decade.
More than half of GUs occur
in males and are less common
than DUs. Common in those
over 50 yr

Pathology
95 % occur most often in 1st
portion
of duodenum with 90% located
within 3 cm of the pylorus.
1 cm in dm can 3- 6 cm
occassionally (giant ulcer),
sharply demarcated, with depth
at times reaching muscularis
propria. The base often consists
can represent a malignancy.
Benign GUs - most often
found distal to the junction
between antrum and acid
secretory mucosa.
associated with H. pylori are
associated
with antral gastritis.
NSAID-related GUs are not
DUODENAL ULCERS: GASTRIC ULCERS
Pathophysiology
H. pylori and NSAID- majority of GUs can
induced injury account be attributed to
for the majority of DUs. either H. pylori or
NSAID-induced
mucosal damage
Accelerated gastric Can occur in prepyloric
emptying of liquids in some area or those in the
patients body.
H. pylori infection may Gastric acid output
contribute to these findings: (basal and stimulated)
Increased average basal and tends to be normal or
nocturnal gastric acid decreased
secretion.
Decreased bicarbonate
secretion.
Outline of the bacterial and host factors important in determining H.
pyloriinduced gastrointestinal disease. MALT, mucosal-associated
lymphoid tissue.
 Risk factors for H. pylori infection
Individuals born before 1950 having
higher rate than those born later (US)
Poor socioeconomic status and less
education
birth or residence in a
developingcountry
domestic crowding
unsanitary living conditions
unclean food or water
exposure to gastric contents of an
infected individual.
Mechanisms by which NSAIDs may induce
mucosal injury
 Risk factors for NSAID
Established risk factors:
include advanced age
history of ulcer
concomitant use of glucocorticoids
high dose NSAIDs
multiple NSAIDs
concomitant use of anticoagulants
serious or multisystem disease
Possible risk factors
concomitant infection with H. pylori
cigarette smoking
alcohol consumption.
 MANIFESTATIONS (HISTORY)
Epigastric pain described as a burning or gnawing
discomfort can be present in both DU and GU.
Duodenal ulcer: Gastric ulcer:
occurs 90 min to 3 h after a discomfort may actually be
meal and is frequently precipitated by food.
relieved by antacids or food. Nausea and weight loss occur
Pain that awakes the patient more commonly
from sleep (between midnight
and 3 A.M.)
 ABDOMINAL PAIN: (possible explanations)
acid-induced activation of chemical receptors in the
duodenum
enhanced duodenal sensitivity to bile acids and pepsin
altered gastroduodenal motility
Variation in intensity or distribution as well onset of
associated symptoms nausea and/or vomiting may be
indicative of an ulcer complication
Dyspepsia that becomes constant no longer relieved by
food or antacids, or radiates to the back may indicate a
penetrating ulcer (pancreas)
Sudden onset of severe, generalized abdominal pain
may indicate perforation.
Pain worsening with meals, nausea, and vomiting of
undigested food suggest gastric outlet obstruction.
Tarry stools or coffee ground emesis indicate bleeding.
 MANIFESTATIONS (P.E)
Epigastric tenderness is the most frequent finding
in patients with GU or DU.
Pain may be found to the right of the midline in
20% of patients.
Tachycardia and orthostasis suggest dehydration
secondary to vomiting or active gastrointestinal
blood loss.
A severely tender, boardlike abdomen suggests a
perforation.
Presence of a succussion splash indicates retained
fluid in the stomach, suggesting gastric outlet
obstruction.
 PUD-Related Complications
1. Gastrointestinal bleeding - most common
complication observed in PUD.
occurs in 15% of patients more often in
individuals 60 years old.
. The higher incidence in the elderly is likely due inc.
use of NSAIDs in this group.
2. PERFORATION 2nd most common ulcer-related
being reported in as many as 6 to 7% of PUD
patients, in the case of bleeding, the incidence of
perforation in the elderly appears to be increasing
secondary to increased use of NSAIDs.
. DUs tend to penetrate posteriorly into the
pancreas, leading to pancreatitis
. GUs tend to penetrate into the left hepatic lobe.
3. Gastric outlet obstruction - least
common ulcer-related complication,
occurring in 1 to 2% of patients.
A patient may have relative
obstruction secondary to ulcer-related
inflammation and edema in the
peripyloric region. This process often
resolves with ulcer healing.
A fixed, mechanical obstruction
secondary to scar formation in the
peripyloric areas is also possible.