Peptic Ulcer
What is Peptic Ulcer?
An ulcer is a round or oval shaped hole (also called parietal defect), 2 to 4 cm in diameter, with perpendicular borders and a smooth base. A Peptic Ulcer is an ulcer in the gastrointestinal tract that is usually acidic and thus extremely painful. It is also called ulcus pepticum or peptic ulcer disease (PUD).
Contrary to general belief, peptic ulcers occur more often in the duodenum (first part of the small intestine) than in the stomach. Duodenal ulcers are generally benign whereas about 4% of stomach ulcers are caused by a malignant tumor. The borders of the Peptic ulcer are not elevated in the acute form but elevated and inflammatory in the chronic form. In the ulcerative form of gastric cancer the borders are irregular. Due to parietal scarring the surrounding mucosa (inner mucus lining) may appear to have radial folds.
Symptoms of Peptic Ulcer
A patient with Peptic Ulcer would have some of the following symptoms:
01) Bloating of the abdomen
02) Waterbrash – this is the rush of saliva in the mouth after an episode of regurgitation in order to dilute the acid in the esophagus
03) Abdominal pain – duodenal ulcers are classically relieved by food while gastric ulcers are exacerbated by it
04) Nausea and a lot of vomiting
05) Loss of appetite
06) Weight loss
07) Hematemesis – vomiting of blood due to gastric ulcer or damage to esophagus from frequent vomiting
08) Heartburn
09) Melena – tarry, foul-smelling feces due to oxidized iron from the hemoglobin
10) Gastric or duodenal perforation (in some severe cases).
The timing of the symptoms in relation to meals may differentiate between gastric and duodenal ulcers. In the gastric ulcer, the pain would be during or after meals because the alkaline duodenal contents reflux into the stomach. In duodenal ulcers the pain would manifest before a meal when acid production increases due to hunger and is passed into the duodenum. However, this is not used as a reliable method of diagnosis.
Diagnosis of Peptic Ulcer
1) Endoscopy: Esophagogastroduodenoscopy (EGD), a form of endoscopy, also known as a gastroscopy, is carried out on patients in whom a peptic ulcer is suspected. By direct visual identification, the location and severity of an ulcer can be diagnosed. Moreover, if no ulcer is present, EGD can often provide an alternative diagnosis. In patients over 45 years with more than two weeks of the above symptoms, the odds for peptic ulceration are high enough to warrant rapid investigation by EGD.
Findings of endscopy: The microscopical appearance of the ulcer shows 4 zones: inflammatory exudate (fluid); fibrinoid necrosis (dead cells); granulation tissue; and fibrous tissue. The fibrous base of the ulcer may contain vessels with thickened wall or with thrombosis (formation of blood clot).
2) Urea breath test: This is a non-invasive test and does not require an endoscopy.
3) Blood test: This is just to check for the presence of antibodies but is not a sufficient diagnostic method for Peptic ulcer.
4) Stool antigen test: This is a non-invasive immunoassay to diagnose active infection with Helicobacter pylori bacteria in fecal samples.
5) Histological examination: The possibility of other causes of ulcers, notably malignancy (gastric cancer) needs to be kept in mind. This is especially true in ulcers of the greater (large) curvature of the stomach.
6) X-ray: This is carried out to rule out perforated Peptic Ulcer. If the air leaks from the gastrointestinal tract (which contains air) to the peritoneal cavity (which never contains air), there would be free gas within the peritoneal cavity. The gas will float to a position underneath the diaphragm and a chest X-ray would show an erect chest and supine, lateral abdomen. This is a sure sign of perforated peptic ulcer and should be treated forthwith.
Causes of Peptic Ulcer
In most cases, tobacco smoking, anorexia (malnutrition), blood group, spicy food and other factors that were suspected to cause ulcers until late in the 20th century, are actually of minor importance in the development of peptic ulcers. But these are factors that aggravate the symptoms of peptic ulcer, once formed. Some of the causes are:
Bacteria: As much as 60% of gastric and up to 90% of duodenal ulcers are associated with Helicobacter pylori, a spiral-shaped bacterium that lives in the acidic environment of the stomach. This bacterium colonizes the antral mucosa (inner mucus lining) and grows rapidly. The antibodies are unable to clear the infection. This causes localized erosion and destruction of the mucosa and results in ulcer formation.
Note: Studies have shown eating cabbage or cabbage juice can rebuild the mucosa lining in the stomach.
Reaction to medications: Ulcers can also be caused or worsened by 
drugs such as aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs). Normally, prostaglandins stimulate the secretion of mucus in the gastrointestinal tract to protect its inner lining from gastric acid. NSAIDs block this function and the risk of ulceration increases. Hence, peptic ulcer due to reaction to medication is found more in aged people suffering from arthritis or those with pain syndromes. Ulcerogenesis can also be caused by the use of glucocorticoids.
Tobacco: Smoking leads to atherosclerosis and vascular spasms. This leads to ischemia (localized reduction of blood flow) and ulcers.
Heredity: A family history is often present in duodenal ulcers, especially when blood group O is also present. But studies show that this is not an important factor in the case of gastric ulcers.
Zollinger Ellison syndrome: Gastrinomas, rare gastrin-secreting tumors, cause multiple ulcers which are difficult to heal.
Types of Peptic Ulcer
Peptic Ulcers are categorized by their location in the body:
1) Gastric Ulcer – in the stomach
2) Duodenal Ulcer – in the duodenum (the first part of the small intestine)
3) Esophageal Ulcer – in the esophagus
4) Meckel’s Diverticulum Ulcer – a small pouch in the wall at the junction of the small and large intestines
5) Prepyloric Ulcer – between inner and outer walls of the stomach
6) Proximal gastresophageal Ulcer – in the mucosa, submucosa, and muscular layer on the lower esophagus, stomach, or duodenum.
Treatment of Peptic Ulcer
Antacids: Young, otherwise healthy patients with ulcer-like symptoms are treated with antacids or H2 antagonists before Endoscopy (EGD) is undertaken. Bismuth compounds may actually reduce or even clear organisms and no further treatment is required.
Antibiotics: When Helicobacter pylori infection is present, the most effective treatments are combinations of any 2 antibiotics lile Clarithromycin, Amoxicillin, Tetracycline or Metronidazole along with a proton pump inhibitor (PPI) and a bismuth compound.
Surgery: Perforated peptic ulcer becomes a surgical emergency and requires surgical repair of the perforation. Most bleeding ulcers require endoscopy urgently to stop the bleeding with cautery (destroying abnormal tissue by burning with electrosurgery) or with injection.
Living with Peptic Ulcer
There are various complications of Peptic Ulcer and the treatment can be lengthy in some cases. Gastrointestinal bleeding is the most common complication. Perforation or hole in the gastro-intestinal wall by the ulcer leads to spillage of stomach or intestinal content into the abdominal cavity. This is called peritonitis. The first sign is often sudden intense abdominal pain. The ulcer penetrates into adjacent organs such as the liver and pancreas. Scarring and swelling causes gastric outlet obstruction.
Prevention of Peptic Ulcer 
There is no proven way to prevent peptic ulcer disease (PUD) but some measure can be taken to reduce the risk:
Reduce use of NSAIDs: Use of non-steroidal anti-inflammatory drugs (NSAIDs) appears to cause ulcers by inhibiting the body’s production of prostaglandins, hormones that protect the stomach lining. Patients should also be prescribed a prostaglandin analogue in order to help prevent peptic ulcers.
Get tested for Helicobacter pylori: If a person has a family history of ulcers, being tested for infection by Helicobacter pylori bacterium can be a preventive measure
Quit smoking: Smokers are about twice as likely to develop ulcers as non-smokers as they are more susceptible to Helicobacter pylori, and provide more favorable conditions for the bacteria to thrive and diminish gastric mucosal defenses.
Reduce stress: There’s conflicting evidence that stress is one of the causes of peptic ulcer and more so in duodenal ulcers. But relaxation exercises like yoga; meditation; and other stress-reducing strategies can help reduce blood pressure and slow heart rate more as a general wellness practice.
Stop alcohol: Alcohol aggravates formation and discomfort from ulcers although it does not cause it.
In Western countries the prevalence of Helicobacter pylori infections roughly matches age. That is, the older the person is the more the risk from peptic ulcer. Prevalence is higher in third world countries.
