formation of Peptic ulcer

How Peptic Ulcer Disease occurs

                  Peptic ulcer disease is defined as ulcerative disorder of the upper gastrointestinal tract that require acid and pepsin for their formation. There are two types of peptic ulcers, a gastric ulcer which forms in the lining of the stomach and a duodenal ulcer which forms in the upper part of the small intestine.

In the digestive system, ulcer is an area of open sores where tissue has been destroyed by the gastric juices and stomach acid. Peptic ulcer disease is a general term for ulcers that occur in the lining of the stomach or of the duodenum (upper part of the small intestine)
                 A peptic ulcer develops in those areas of the gastrointestinal tract that are usually acidic. Most ulcers are known to be associated with Helicobacter pylori, a spiral shaped bacterium that lives in the acidic environment of the stomach. Ulcers can also be caused by drugs such as aspirin and other NSAIDS. 
                 It is estimated that 5-10% peptic ulcers are seen, duodenal ulcers are four times more common than gastric ulcers. Males are more prone to peptic ulcers than females. About 4% of gastric ulcers are caused by a malignant tumor, which is one of the reason to be vigilant in their detection. Duodenal ulcers are generally benign.

The three forms of peptic ulcer include:
  • H. Pylori associated ulcers.
  • NSAIDS associated ulcers
  • Stress related mucosal damage  
  • Others: External trauma, excessive intake of coffee, extensive burns, some drugs like indomethacin, aspirin, some local irritants, psychological stress, alcohol etc… 
  • Abdominal pain
  • Epigastric pain
  • Abdominal fullness
  • Abdominal cramps
  • Hematemesis (vomiting of blood)
  • Melena (tarry, foul smelling feces)
  • Weight loss
  • Heart burn
  • Belching
  • Bloating
  • Nausea, vomiting, anorexia
  • GI bleeding
A major causative factor (75% gastric and 90% duodenal ulcers) is chronic inflammation due to H. pylori, it inhibits the antral mucosa and infuses gastrin production which in turn stimulate the production of gastric acid by parietal cells.

            Another major cause is the use of NSAIDS the gastric mucosa protects a layer of mucus from gastric acid which is stimulated by certain prostaglandins. NSAIDS blocks the function of cyclooxygenase-1 which is essential for the production of these prostaglandins. Stress in the psychological sense has not been proved to influence the development of peptic ulcers.

  • Physical examination: It may reveal epigastric tenderness between the umbilicus under xyphoid process that less commonly radiates to the back.
  • Esophagogastroduodenoscopy: It is a form of endoscopy where the location and severity of ulcer can be visually seen. 
  • Biopsy during EGD
  • Blood test: routine blood test are not helpful in establishing the diagnosis of PUD. Hematocrit, Hemoglobin, and stool guaiac tests are used to detect bleeding.
  • Visualization: Diagnosis of PUD depends on visualizing the ulcer crater either by upper GI radiography or endoscopy.
  • Serologic anti body detection



First line therapy to eradicate H.P infection is usually initiated with a proton pump inhibitor 3-drug regimen for 14 days. If a second treatment course is required, the salvage regimen should contain different antibiotics or a 4-drug regimen with bismuth salt, metronidazole, tetracycline, and a PPI.   
  • The treatment for the peptic ulcers depends on the cause. Usually the medications include:
    Antibiotic medications to kill H. pylori: If H. pylori is found in your digestive tract, then antibiotics are used to kill the bacterium. These may include amoxicillin, clarithromycin, metronidazole, tinidazole, tetracycline, levofloxacin. 
    These antibiotics must be taken for two weeks including a proton pump inhibitor and possibly bismuth subsalicylate (Pepto-Bismol)
*  Medications that block acid production and promote healing:    
    The proton pump inhibitors reduce stomach acid by blocking the action of the parts of cells that produce acid. These drugs include OTC medications such as omeprazole, lansoprazole, rabeprazole, esomeprazole, pantoprazole.
    Long term use of proton pump inhibitors, particularly at high doses, may increase the risk of hip, wrist and spine fracture. Calcium supplements must be given additionally to reduce this risk.
 Medications to reduce acid production:
Acid blockers also called as histamine blockers are used to reduce the amount of stomach acid released into your digestive tract, which relieves ulcer pain and encourages healing.
Drugs include ranitidine, famotidine, cimetidine, nizatidine.
*Antacids neutralize the stomach acid and provide rapid pain relief. Side effects may include constipation or diarrhea 
Medications that protect the lining of the stomach and small intestine:
In some conditions the cytoprotective agents that help in protecting the tissues lining the stomach and small intestine are been used. Drugs such as sucralfate, misoprostol.

Peptic ulcers that don’t recover by treatment are called refractory ulcers. There are many reasons for these refractory ulcers:
  • Not taking medications according to directions
  • Some types of H. pylori are resistant to antibiotics
  • Regular use of tobacco
  • Regular use of pain killers- NSAIDS and aspirin- that increase the risk of ulcers.
     Less often these refractory ulcers may be a result of 
  • Other infection than H. pylori
  • Stomach cancer
  • Overproduction of stomach acid which occur in Zollinger-Ellison syndrome.
  • Other diseases that may cause ulcer like sores in stomach and small intestine, such as Crohn’s disease.
The treatment for refractory ulcers involves eliminating factors that may interfere with healing, along with using different antibiotics. If any complications like acute bleeding or perforations surgery is required
  • Choose a healthy diet: fruits especially with vitamins A and C, vegetables, whole grains. Lack of vitamin rich foods may make it difficult for the body to heal ulcers.
  • Consider the foods containing probiotics: yogurt, aged cheeses.
  • Control stress: stress may worsen the signs and symptoms of peptic ulcer
  • Avoid smoking and alcohol
                                                                                                                            Presented by
                                                                                                          M. Keerthi Kumari,  S.Sai Sushma




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