PEPTIC ULCERPEPTIC ULCER

DEFINITION AND DESCRIPTIONDEFINITION AND DESCRIPTION

♥ Peptic ulcers are produced by an imbalance between the gastro-duodenal mucosal defense mechanisms and damaging forces of gastric acid and pepsin, combined with superimposed injury from environmental or immunologic agents.

♥The mucous membrane lining the digestive tract erodes and causes a gradual breakdown of tissue.  This breakdown causes a gnawing or burning pain in the upper middle part of the belly (abdomen).

BOSSES

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₪ As many as 80% of ulcers are associated with Helicobacter pylori, a spiral-shaped bacterium that lives in the acidic environment of the stomach.

₪ Ulcers can also be caused or worsened by drugs such as aspirin and other NSAIDs.

₪ Although H. pylori infection is usually contracted in childhood, perhaps through food, water, or close contact with an infected individual. usually doesn't cause problems in childhood, if left untreated it can cause gastritis (the irritation and inflammation of the lining of the stomach), peptic ulcer disease, and even stomach cancer later in life.

₪ Contrary to general belief, more peptic ulcers arise in the duodenum (first part of the small intestine, just after the stomach) than in the stomach.

₪ Duodenal ulcers usually first occur between the ages of 30-50 years and are twice as common in men as in women.

₪  Stomach (or gastric) ulcers usually occur in people older than 60 years and are more common in women.

SYMPTOMS

Gastric versus duodenal ulcer — Although there is much overlap, symptoms of a gastric ulcer may be different than those of a duodenal ulcer.

Duodenal ulcer — "Classic" symptoms of a duodenal ulcer include burning, gnawing, aching, or hunger-like pain, primarily in the upper middle region of the abdomen below the breastbone (the epigastric region). Pain may occur or worsen

when the stomach is empty, usually two to five hours after a meal. Symptoms may occur at night between 11 PM and 2 AM, when acid secretion tends to be greatest.

Feel better when you eat or drink and then worse 1 or 2 hours later (duodenal ulcer) Gastric ulcer — Symptoms of a gastric ulcer typically include pain soon after eating.

Symptoms are sometimes not relieved by eating or taking antacids.Feel worse when you eat or drink (gastric ulcer)

SYMPTOMS

Burning painBurning pain bloating bloating

NauseaNausea water brashwater brash

Unexplained weight lossUnexplained weight loss hematemesis (vomiting of blood)hematemesis (vomiting of blood)

Appetite changes  Appetite changes   MelinaMelina

vomitingvomiting Blood in the stoolsBlood in the stools

low blood cell count (anemia)low blood cell count (anemia) Stomach pain wakes you up at nightStomach pain wakes you up at night

frequent burping or hiccuppingfrequent burping or hiccupping An early sense of fullness with eatingAn early sense of fullness with eating

CAUSESCAUSES

Helicobacter pylori infectionHelicobacter pylori infection

Helicobacter pylori infection 

¤H. pylori is a helix-shaped¤ Gram-negative, slow-growing organism ¤ about 3 micrometres long with a diameter of about 0.5 micrometres¤has 4–6 flagella¤ Helicobacter pylori is composed of a single circular chromosome with 1,667,867 base pairs, containing about 1590 coding regions¤It is microaerophilic; that is, it requires oxygen, but at lower concentration than is found in the atmosphere¤It contains a hydrogenase which can be used to obtain energy by oxidizing molecular hydrogen (H2) that is produced by intestinal bacteria

☻The bacterium persists in the stomach for decades in most people. Most individuals infected by H. pylori will never experience clinical symptoms despite having chronic gastritis. Approximately 10-20% of those colonized by H. pylori will ultimately develop gastric and duodenal ulcers. H. pylori infection is also associated with a 1-2% lifetime risk of stomach cancer and a less than 1% risk of gastric MALT lymphoma

• Regular use of pain relievers. Nonsteroidal anti-inflammatory drugs (NSAIDs) can irritate the lining of stomach and small intestine. These medications, which are available both by prescription and over-the-counter, include aspirin, ibuprofen (Advil, Motrin, others), naproxen (Aleve), ketoprofen and others. Other prescription medications that can also lead to ulcers include medications used to treat osteoporosis called bisphosphonates (Actonel, Fosamax and others).

• NSAIDs inhibit production of an enzyme (cyclooxygenase) that produces prostaglandins. These hormone-like substances help protect stomach lining from chemical and physical injury. Without this protection, stomach acid can erode the lining, causing bleeding and ulcers.

• Gastrinomas (Zollinger Ellison syndrome), rare gastrin-secreting tumors, also cause multiple and difficult to heal ulcers.

• Excessive alcohol consumption Alcohol can irritate and erode the mucous lining of stomach and increases the amount of stomach acid that's produced. It's uncertain, however, whether this alone can progress into an ulcer or if it just aggravates the symptoms of an existing ulcer.

NICOTINEparasympathetic nerveparasympathetic nerve

activity in activity in gastrointestinal tractgastrointestinal tract

increase

stimulation to stimulation to the enterochromaffin-like cells the enterochromaffin-like cells

and G cellsand G cells

increases the increases the amount amount

of histamine and of histamine and gastrin secretedgastrin secreted

• Caffeine

Beverages and foods that contain caffeine can stimulate acid secretion in the stomach. This can aggravate an existing ulcer, but the stimulation of stomach acid can't be attributed solely to caffeine.

Role of StressRole of Stress

♫ A study of peptic ulcer patients in a Thai hospital showed that chronic stress was strongly associated with an increased risk of peptic ulcer, and a combination of chronic stress and irregular mealtimes was a significant risk factoR.

♫ An expert panel convened by the Academy of Behavioral Medicine Research concluded that ulcers are not purely an infectious disease and that psychological factors do play a significant role. Researchers are examining how stress might promote H. pylori infection.

♫ For example, Helicobacter pylori thrives in an acidic environment, and stress has been demonstrated to cause the production of excess stomach acid. This was supported by a study on mice showing that both long-term water-immersion-restraint stress and H. pylori infection were independently associated with the development of peptic ulcers.

♫ Physical stress, is different. It can increase the risk of developing ulcers, especially in the stomach. Examples of physical stress that can lead to ulcers are that suffered by people with injuries such as severe burns, and people undergoing major surgery.

Risk Factors for UlcersRisk Factors for Ulcers

• You’re at risk for peptic ulcer disease if you:• Are 50 years old or older.• Diabetes may increase your risk of having H. pylori• Drink alcohol excessively• Smoke cigarettes or use tobacco.• Have a family history of ulcer disease.• You’re at risk for NSAID-induced ulcers if you:• Are age 60 or older (your stomach lining becomes more fragile with age).• Have had past experiences with ulcers and internal bleeding• Take steroid medications, such as prednisone.• Take blood thinners, such as warfarin.• Consume alcohol or use tobacco on a regular basis.• Experience certain side effects after taking NSAIDs, such as upset stomach

and heartburn.• Take NSAIDs in amounts higher than recommended • Take NSAIDs for long periods of time• Stress does not cause an ulcer, but may be a contributing factor• Chronic disorders such as liver disease, emphysema, rheumatoid arthritis

may increase vulnerability to ulcers Improper diet, irregular or skipped meals Type O blood (for duodenal ulcers)

COMPLICATIONSCOMPLICATIONS

ж Gastrointestinal bleeding is the most common complication. Sudden large bleeding can be life-threatening. It occurs when the ulcer erodes one of the blood vessels. Bleeding can occur as slow blood loss that leads to anemia or as severe blood loss that may require hospitalization or a blood transfusion.

ж Perforation (a hole in the wall) often leads to catastrophic consequences. Erosion of the gastro-intestinal wall by the ulcer leads to spillage of stomach or intestinal content into the abdominal cavity. Perforation at the anterior surface of the stomach leads to acute peritonitis, initially chemical and later bacterial peritonitis. The first sign is often sudden intense abdominal pain. Posterior wall perforation leads to pancreatitis; pain in this situation often radiates to the back.

ж Penetration is when the ulcer continues into adjacent organs such as the liver and pancreas

ж Scar tissue Scarring and swelling due to ulcers causes narrowing in the duodenum and gastric outlet obstruction. Patient often presents with severe vomiting. Peptic ulcers can also produce scar tissue that can obstruct passage of food through the digestive tract, causing you to become full easily, to vomit and to lose weight.

WARNING SIGNSWARNING SIGNS

blood in your stoolsblood in your stools losing weightlosing weight pain doesn't go awaypain doesn't go away

With medicationWith medication

vomit bloodvomit blood sudden, severe painsudden, severe pain

vomit food eaten hours or vomit food eaten hours or

days beforedays before

ongoing nausea or ongoing nausea or repeated vomiting. repeated vomiting.

feel cold or clammyfeel cold or clammy feel unusually weak or feel unusually weak or

dizzydizzy

TESTS AND DIAGNOSIS CHARTTESTS AND DIAGNOSIS CHART

Noninvasive

Urea Breath Test (UBT) Blood test

Invasive

Biopsy Urease Test Histology

Culture

Stool antigen test

Upper gastrointestinal (upper GI) X-ray

Other tests

Endoscopy

TREATMENT

Sammyz 7’zzzz☻ lowering the amount of acid that stomach makes, ☻neutralizing the acid ☻ protecting the injured area so it can heal☻ It's also very important to stop smoking and drinking alcohol☻Prevent complications (bleeding, perforation, penetration, obstruction) ☻Minimize recurrences ☻Reduce financial costs

Antibiotic medications. Doctors use combinations of antibiotics to treat H. pylori because one antibiotic alone isn't always sufficient to kill the organism. Antibiotics prescribed for treatment of H. pylori include amoxicillin (Amoxil), clarithromycin (Biaxin) and metronidazole (Flagyl). Combination drugs that include two antibiotics together with an acid suppressor or cytoprotective agent (Helidac, Prevpac) have been designed specifically for the treatment of H. pylori infection.

Acid blockers. Acid blockers — also called histamine (H-2) blockers — reduce the amount of hydrochloric acid released into 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 body. When it reacts with histamine receptors, the receptors signal acid-secreting cells in 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. 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 and over-the-counter medications omeprazole (Prilosec), lansoprazole (Prevacid), rabeprazole (Aciphex) and esomeprazole (Nexium). Doctors frequently prescribe proton pump inhibitors to promote the healing of peptic ulcers. Proton pump inhibitors also appear to inhibit H. pylori.

♪ 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).

♪ Bowel rest: Bed rest and clear fluids with no food at all for a few days. This gives the ulcer a chance to start healing without being irritated. 

♪ Nasogastric tube: Placement of a thin, flexible tube through your nose and down into your stomach. This also relieves pressure on the stomach and helps it heal. ♪ Urgent endoscopy or surgery if indicated: Damaged, bleeding blood vessels can usually be repaired with an endoscope. The endoscope has a small heating device on the end that is used to cauterize a small wound.

SurgerySurgery

Vagotomy Antrectomy Pyloroplasty Tying off an 

artery

Acupuncture Chiropractic Homeopathy Herbs

Other modesOf treatment

LIFE STYLE AND HOME REMEDIESLIFE STYLE AND HOME REMEDIES

Don't smokeDon't smoke

Limit or avoid alcoholLimit or avoid alcohol

Avoid nonsteroidal Avoid nonsteroidal anti-inflammatory anti-inflammatory

drugs (NSAIDs)drugs (NSAIDs)

Fruits and Fruits and VegetablesVegetables

LessLessCoffee and Coffee and Carbonated Carbonated BeveragesBeverages

Use of Olive OilUse of Olive Oil

ExerciseExercise

Stress ReliefStress Relief

STUDIES STUDIES & RECENT RESEARCHES& RECENT RESEARCHES

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