PEPTIC ULCER

DISEASE
(PUD)
Definition:
ØAn excavation (hollowed-out area) that forms
in the mucosal wall of the stomach, in the
pylorus (the opening the stomach and
duodenum), in the duodenum (the first part of
small intestine), or in the esophagus. Erosion of
a circumscribed area of mucous membrane is
the cause. This Erosion may extend as deeply as
the muscle layers or through the muscle to the
peritoneum.
Classifications:
ØStomach (called gastric ulcer)

ØDuodenum (called duodenal ulcer)

ØEsophagus (called esophageal ulcer)

ØMeckel's Diverticulum (called Meckel's Diverticulum ulcer)

Types:
Ø
ØType I: Ulcer along the lesser curve of stomach
ØType II: Two ulcers present - one gastric, one duodenal
ØType III: Prepyloric ulcer
ØType IV: Proximal gastro esophageal ulcer
ØType V: Anywhere along gastric body, NSAID induced
Ø
 Causes:
ØHelicobacter Pylori
ØNonsteroidal Anti-inflammatory Drug (NSAID)
ØTobacco Smoking
ØStress
ØCaffeine
Helicobacter Pylori:
A major causative factor (60% of gastric and up to 90% of
duodenal ulcers) is chronic inflammation due to
Helicobacter pylori that colonizes the antral mucosa. The
immune system is unable to clear the infection, despite the
appearance of antibodies. Thus, the bacterium can cause a
chronic active gastritis (type B gastritis), resulting in a
defect in the regulation of gastrin production by that part
of the stomach, and gastrin secretion can either be
decreased (most cases) resulting in hypo- or achlorhydria
or increased. Gastrin stimulates the production of gastric
acid by parietal cells and, in H. pylori colonization
responses that increase gastrin, the increase in acid can
contribute to the erosion of the mucosa and therefore ulcer
formation.
Nonsteroidal Anti Inflammatory Drug:
Another major cause is the use of NSAIDs. The gastric
mucosa protects itself from gastric acid with a layer of
mucus, the secretion of which is stimulated by certain
prostaglandins. NSAIDs block the function of
cyclooxygenase 1 (cox-1), which is essential for the
production of these prostaglandins. COX-2 selective anti-
inflammatories (such as celecoxib or the since withdrawn
rofecoxib) preferentially inhibit cox-2, which is less
essential in the gastric mucosa, and roughly halve the risk
of NSAID-related gastric ulceration. As the prevalence of H.
pylori-caused ulceration declines in the Western world due
to increased medical treatment, a greater proportion of
ulcers will be due to increasing NSAID use among
individuals with pain syndromes as well as the growth of
aging populations that develop arthritis.
Tobacco Smoking:
Tobacco smoking leads to atherosclerosis and vascular
spasms, causing vascular insufficiency and promoting the
development of ulcers through ischemia. Nicotine
contained in cigarettes can increase parasympathetic
nerve activity to the gastrointestinal tract by acting on the
nicotinic receptors at synapses - increased stimulation to
the enterochromaffin-like cells and G cells increases the
amount of histamine and gastrin secreted and therefore
increases the acidity of the gastric juice. Similarly,
glucocorticoids lead to atrophy of all epithelial tissues.
However, these factors, along with diet or spices, blood
type, and other factors suspected to cause ulcers until
late in the 20th century, are actually of relatively minor
importance in the development of peptic ulcers.
Stress:
Researchers also continue to look at stress as a
possible cause, or at least complication, in the
development of ulcers. There is debate as to whether
psychological stress can influence the development of
peptic ulcers. Burns and head trauma, however, can
lead to physiologic stress ulcers, which are reported
in many patients who are on mechanical ventilation.
Caffeine:
Ø
Caffeine seems to stimulate acid secretion in
the stomach, which can aggravate the pain of
an existing ulcer. However, the stimulation of
stomach acid cannot be attributed solely to
caffeine.
Ø
 Signs & Symptoms:
Øabdominal pain, classically epigastric with severity relating to
mealtimes, after around 3 hours of taking a meal (duodenal ulcers are
classically relieved by food, while gastric ulcers are exacerbated by
it);

Øbloating and abdominal fullness;

Øwaterbrash (rush of saliva after an episode of regurgitation to dilute

the acid in esophagus);

Ønausea, and copious vomiting;

Øloss of appetite and weight loss;

Øhematemesis (vomiting of blood); this can occur due to bleeding

directly from a gastric ulcer, or from damage to the esophagus from
severe/continuing vomiting.

Ømelena (tarry, foul-smelling feces due to oxidized iron from

hemoglobin);

Ørarely, an ulcer can lead to a gastric or duodenal perforation. This is

extremely painful and requires immediate surgery.
Risk Factors:

ØHelicobacter Pylori
Ø
ØUse of Nonsteroidal Anti-Inflammatory Drug (NSAIDs)
Ø
ØAlcohol
Ø
ØTobacco Smoking
Ø
ØCirrhosis
Ø
ØStress
Ø
ØGastritis
Different Laboratory and Diagnostic Procedures
An 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 described.

The diagnosis of Helicobacter pylori can be made by:

ØUrea breath test (noninvasive and does not require EGD);

ØDirect culture from an EGD biopsy specimen; this is difficult to do, and can
be expensive. Most labs are not set up to perform H. pylori cultures;

ØDirect detection of urease activity in a biopsy specimen by rapid urease

test;

ØMeasurement of antibody levels in blood (does not require EGD). It is still

somewhat controversial whether a positive antibody without EGD is enough
to warrant eradication therapy;

ØStool antigen test;

ØHistological examination and staining of an EGD biopsy.

Macroscopic appearance
Gastric ulcers are most often localized on the lesser curvature of the
stomach. The ulcer is a round to oval parietal defect ("hole"), 2 to
4 cm diameter, with a smooth base and perpendicular borders. These
borders are not elevated or irregular in the acute form of peptic ulcer,
regular but with elevated borders and inflammatory surrounding in
the chronic form. In the ulcerative form of gastric cancer the borders
are irregular. Surrounding mucosa may present radial folds, as a
consequence of the parietal scarring.

Microscopic appearance
A gastric peptic ulcer is a mucosal defect which penetrates the
muscularis mucosae and muscularis propria, produced by acid-pepsin
aggression. Ulcer margins are perpendicular and present chronic
gastritis. During the active phase, the base of the ulcer shows 4
zones: inflammatory exudate, fibrinoid necrosis, granulation tissue
and fibrous tissue. The fibrous base of the ulcer may contain vessels
with thickened wall or with thrombosis.
Differential diagnosis of epigastric pain

ØPeptic ulcer ØBiliary colic

Ø
ØGastritis ØInferior myocardial infarction
Ø
ØStomach cancer ØReferred pain
(pleurisy, pericarditis)
ØGastroesophageal Ø
reflux disease ØSuperior mesenteric artery
syndrome
ØPancreatitis

ØHepatic congestion

ØCholecystitis
 Pathophysiology:

with alcohol
Acid andabuse,
pepsinogen
smoking,
release
use of
with
aspirin
chronic
and vagal
NSAIDsInfection
response to
with
increased
Helicobacter
stressPylori

Damaged mucosal barrier

Imbalance of aggressive and defensive factor

Low of mucosal cells; Low quality of mucous; Less of tight juntion between cells
 Infection gives increased gastrin and decreased somatostation production

astritis inflammation >> decreased acid and intrinsic factor

Mucosal ulcerations, possible bleeding and scarring

Severe Ulcerations:

ould not secrete enough mucus to act as a barrier against gastric

Signs and acid
Symptoms:
ØEpigastric pain
ØHematemesis
ØDsypepsia
ØPyrosis
Medical Management:

ØPerioperative Management of the Patient With Liver Disease

(Perioperative Care)The number of patients with cirrhosis who
require surgery is on the rise. Despite advances in antiviral
therapeutics, the prevalence of cirrhosis secondary

ØPeptic Ulcer Disease (Gastroenterology)Peptic ulcer disease (PUD)

is a common disorder that affects millions of individuals in the
United States each year. PUD has a major impact on our health

ØGastric Ulcers (Gastroenterology) Peptic ulcer disease (PUD) is one

of the most common diseases affecting the gastrointestinal (GI)
tract. It causes inflammatory injuries in the gastric

ØPeptic Ulcer Disease (Pediatrics: General Medicine) The lesion of

peptic ulcer disease (PUD) is a disruption in the mucosal layer of the
stomach or duodenum. An ulcer is distinguished from an erosion by
its ...
ØPerforated Peptic Ulcer (General Surgery) The treatment of peptic
ulcer disease (PUD) that involves duodenal bulb and prepyloric ulcers
continues to evolve.

ØZollinger-Ellison Syndrome (Pediatrics: General Medicine)

characterized by peptic ulcers that are refractory to conventional
medical therapy. Gastrin-producing tumors or gastrinomas cause
excessive gastric.
Ø
ØDuodenal Ulcers (Gastroenterology) When we speak of duodenal
ulcers, we often imply that these are part of what is known as peptic
ulcer disease; duodenal ulceration may be only rare.
Ø
ØUpper Gastrointestinal Bleeding, Surgical Treatment (General Surgery)
life-threatening abdominal emergency that remains a common cause of
hospitalization. The incidence of upper gastrointestinal bleeding (UGIB).

ØGastroesophageal Reflux Disease (Gastroenterology) after a meal.

Gastroesophageal reflux disease (GERD) occurs when the amount of
gastric juice that refluxes into the esophagus exceeds the normal limit.
ØHelicobacter Pylori Infection (Gastroenterology). At first, they named
the bacterium Campylobacter pyloridis. Later, it was named
Campylobacter pylori. Since then, a large number of reports have been
PUD
Ø
ØHelicobacter Pylori Infection (Pediatrics: General Medicine) Helicobacter
pylori (Hp) is a gram-negative bacillus responsible for one of the most
common infections found in humans worldwide.

ØGastric Outlet Obstruction (General Surgery) not a single entity; it is

the clinical and pathophysiological consequence of any disease process
that produces a mechanical impediment to gastric.
Ø
ØAfferent Loop Syndrome (Gastroenterology) mechanical complication
that infrequently occurs following construction of a gastrojejunostomy.
Creation of an anastomosis between the stomach.
Ø
ØEsophagitis (Gastroenterology) The most common cause of esophagitis
is Gastroesophageal Reflux Disease (GERD). Other important, but less
common, causes are infections, medications.
ØGastrointestinal Disease and Pregnancy (Gastroenterology)
Gastrointestinal (GI) disorders are some of the most frequent
complaints during pregnancy. Some women have certain GI disorders.

ØGastritis and Peptic Ulcer Disease (Emergency Medicine) Gastritis

includes a myriad of disorders that involve inflammatory changes in
the gastric mucosa, including erosive gastritis caused by Helicobacter
pylori.
Ø
ØGastritis, Stress-Induced (Gastroenterology) Cardiology, State
University of New York-Downstate Medical Center, University Hospital
of Brooklyn.
Ø
ØCervical Sprain and Strain (Physical Medicine and Rehabilitation)
Cervical strain is one of the most common musculoskeletal problems
encountered by generalists and neuromusculoskeletal specialists in
the clinic.
Ø
ØPlatelet Disorders (Hematology) The hemostatic system consists of
platelets, coagulation factors, and the endothelial cells lining the
blood vessels.
ØPostcholecystectomy Syndrome (General Surgery) The term
postcholecystectomy syndrome (PCS) describes the presence of
symptoms after cholecystectomy.
Ø
ØAbdominal Pain in Elderly Persons (Emergency Medicine) The
evaluation of elderly patients presenting with abdominal pain poses
a difficult challenge for the emergency physician.
Ø
ØTenosynovitis (Emergency Medicine) Tenosynovitis involves
inflammation of the tendon and tendon sheath. Examples of
tenosynovitis include de Quervain tenosynovitis of the wrist.
Ø
ØTendonitis (Emergency Medicine) into bone. The term tendinosis
refers to the histopathologic finding of tendon degeneration.

ØPemphigoid Gestationis (Dermatology) Pemphigoid gestationis (PG)

is a rare autoimmune bullous dermatosis of pregnancy. The disease
was originally named herpes gestationis.
Ø
ØDermatitis, Exfoliative (Emergency Medicine) is an erythematous,
scaly dermatitis involving most, if not all, of the skin.
Ø