Peptic Ulcer

Definition

A hole in the lining of the stomach, duodenum, or esophagus. A peptic ulcer of the stomach is called a gastric ulcer, an ulcer of the duodenum is a duodenal ulcer, and a peptic ulcer of the esophagus is an esophageal ulcer. A peptic ulcer occurs when the lining of these organs is corroded by the acidic digestive juices which are secreted by the stomach cells.

 

 

Types of peptic ulcer

Gastric ulcer. This is a peptic ulcer that occurs in your stomach.

Duodenal ulcer. This type of peptic ulcer develops in the first part of the small intestine (duodenum).

Esophageal ulcer. An esophageal ulcer is usually located in the lower section of your esophagus. It's often associated with chronic gastroesophageal reflux disease (GERD).

 

 

 Symptoms of peptic ulcers

A burning pain in the gut is the most common symptom. The pain feels like a dull ache comes and goes for a few days or weeks starts 2 to 3 hours after a meal comes in the middle of the night when your stomach is empty usually goes away after you eat.

Other symptoms are

1. losing weight

2. not feeling like eating

3. having pain while eating

4. feeling sick to your stomach

5. vomiting

Risk Factors for Ulcer

 

Helicobacter pylori infection — The exact source of Helicobacter pylori is not known, but it may be transmitted by person-to-person contact. Be sure to always wash your hands after using the bathroom and before eating.

 

Over-the-counter pain medications such as aspirin or ibuprofen — Frequent use of these medications can block the production of certain substances that protect the stomach lining. If you have an ulcer, limit or eliminate use of these kinds of drugs.

 

Alcohol consumption — Alcohol irritates the stomach lining and increases stomach acid output.

Smoking — Smoking increases the volume and concentration of acid secreted by the stomach. If you have an ulcer, quit smoking.

 

Family history of ulcers — People with family members with ulcers are more susceptible to getting them; the reason for this is not known

Diagnosis

Diagnosis of peptic ulcer is suggested by patient history and confirmed by endoscopy.

Empiric therapy is often begun without definitive diagnosis. However, endoscopy allows for biopsy or cytologic brushing of gastric and esophageal lesions to distinguish between simple ulceration and ulcerating stomach cancer.

Stomach cancer may present with similar manifestations and must be excluded, especially in patients who are > 45, have lost weight, or report severe or refractory symptoms. The incidence of malignant duodenal ulcer is extremely low, so biopsies of lesions in that area are generally not warranted. Endoscopy can also be used to definitively diagnose H. pylori infection, which should be sought when an ulcer is detected.

Gastrin-secreting malignancy and Zollinger-Ellison syndrome should be considered when there are multiple ulcers, when ulcers develop in atypical locations (eg, postbulbar) or are refractory to treatment, or when the patient has prominent diarrhea or weight loss. Serum gastrin levels should be measured in these patients.

Treatment

Antibiotic medications. Doctors use combinations of antibiotics to treat H. pylori because one antibiotic alone isn't sufficient to kill the organism. For the treatment to work, it's essential that you follow your doctor's instructions precisely. Antibiotics commonly prescribed for treatment of H. pylori include amoxicillin (Amoxil), clarithromycin (Biaxin) and metronidazole (Flagyl). Some companies package a combination of two antibiotics together, with an acid suppressor or cytoprotective agent specifically for treatment of H. pylori infection. These combination treatments are sold under the names Prevpac and Helidac. Other medications prescribed in conjunction with antibiotics generally are taken for a longer period.

Acid blockers. Acid blockers - also called histamine (H-2) blockers - reduce the amount of hydrochloric acid released into your digestive tract, which relieves ulcer pain and encourages healing. Acid blockers work by keeping histamine from reaching histamine receptors. Histamine is a substance normally present in your body. When it reacts with histamine receptors, the receptors signal acid-secreting cells in your stomach to release hydrochloric acid. Available by prescription or over-the-counter (OTC), acid blockers include the medications ranitidine (Zantac), famotidine (Pepcid), cimetidine (Tagamet) and nizatidine (Axid).

Antacids. Your doctor may include an antacid in your drug regimen. An antacid may be taken in addition to an acid blocker or in place of one. Instead of reducing acid secretion, antacids neutralize existing stomach acid and can provide rapid pain relief.

Proton pump inhibitors. Another way to reduce stomach acid is to shut down the "pumps" within acid-secreting cells. Proton pump inhibitors reduce acid by blocking the action of these tiny pumps. These drugs include the prescription medications omeprazole (Prilosec), lansoprazole (Prevacid), rabeprazole (Aciphex) and esomeprazole (Nexium). The drug pantoprozole (Protonix) can be taken orally or administered intravenously in the hospital. Proton pump inhibitors are frequently prescribed to promote the healing of peptic ulcers.

If you are admitted to the hospital with a bleeding ulcer, taking intravenous proton pump inhibitors decreases the chance that bleeding will recur. Proton pump inhibitors also appear to inhibit H. pylori. However, long-term use of proton pump inhibitors, particularly at high doses, may increase your risk of hip fracture.

Cytoprotective agents. In some cases, your doctor may prescribe these medications that help protect the tissues that line your stomach and small intestine. They include the prescription medications sucralfate (Carafate) and misoprostol (Cytotec). Another nonprescription cytoprotective agent is bismuth subsalicylate (Pepto-Bismol). In addition to protecting the lining of your stomach and intestines, bismuth preparations appear to inhibit H. pylori activity.

Histology of peptic ulcer 

Figure 1:

Peptic ulcer of stomach (arrow). The whole mucosa and part of submucosa are denuded.(M: mucosa, SM: submucosa, MP: muscularis propria)

Figure2: 

Four zones of active peptic ulcer.The necrotic fibrinoid debris and nonspecific inflammatory infiltrate are labeled by arrowhead. Beneath the necrotic and inflammatory zones, there is granulation tissue (arrow). Below the granulation tissue, fibrotic tissue is seen (F).

Figure 3:

Granulation tissue in the ulcer base. New blood vessels lined byplump endothelial cells (arrow). Edema and inflammatory infiltrate are also seen

Figure 4:

Intestinal metaplasia in chronic gastritis. The gastric foveolar epithelium (arrowhead) is replaced by intestinal type of epithelium (arrow).The intestinal epithelium has goblet cells

(all figures taken from http://pathology.tmu.edu.tw )