Peptic Ulcer

Definition -Ulcer along the GI tract due to acid-peptic digestion.

Sites
● Duodenal ulcer-1st part of duodenum
● Gastric ulcer-Lesser curvature of stomach
● Multiple ulcers at duodenum,Jejunum or oesophagus-Zollinger-Ellison’s syndrome
● Meckel’s diverticulum that contains ectopic gastric epithelium
Duodenal ulcers occur four times more commonly than gastric ulcers.

Classifications

Peptic ulcers can be broadly classified into:

• Gastric ulcers (type I, body and fundal).

• Duodenal and gastric ulcers (type II, prepyloric).

• Atypical ulceration.

Gastric ulceration

• ♂:♀, 3:1; peak age of incidence 50y.

• Associated with Helicobacter (H.) pylori in 45% of cases and with high alcohol intake,
smoking, NSAID use, normal or low acid secretion.

Duodenal and type II gastric ulceration

• ♂:♀, 5:1; peak age of incidence 25–30y.

• Associated with H. pylori in 85% of cases and with high acid secretion, smoking, NSAID
use.

Atypical ulceration

• Usually due to either atypical sites of gastric acid secretion (e.g.

ectopic gastric mucosa in a Meckel’s diverticulum) or abnormally high levels of acid
secretion (e.g. Zollinger–Ellison syndrome)

• Associated with ulceration that fails to respond to maximal medical therapy, multiple ulcers,
ulcers in abnormal locations (e.g. distal duodenum or small bowel).

Pathology
Aetiology
1. Infection -H.pylori infection
2. Drugs-Aspirin and other NSAIDs ,Corticosteroid in high dose and repeated use.
 3. Life-style-Smoking,High alcohol intake,Social and physical stress,Eating spicy food.
4. Endocrine disease-Zollinger-Ellison’s syndrome,Cushing’s
syndrome,Hyperparathyroidism
5. Others -Blood group O

Clinical features

• Nausea and epigastric pain.

• Duodenal ulceration typified by hunger pains with central back pain relieved by food; pain
is often cyclical and occurs in the early hours of the morning.
• Gastric ulceration typified by pain precipitated by food with associated weight loss and
anorexia; pain less cyclical.
• Vomiting and upper abdominal distension suggest gastric outlet obstruction.

Investigations

● Gastroduodenoscopy(investigation of choice)
● Barium meal. May be used if gastroscopy contraindicates.
● Biopsies of antrum to see histological evidence of gastritis
● CLO test to determine the presence of H. pylori.
● Fasting serum gastrin levels. If hypergastrinemia is suspected.
● FBC -Bleeding from PU
● USG-to exclude other causes of epigastric pain.

Complications

• Acute upper GI bleeding (Haematemesis and malena)

• Iron deficiency anaemia due to chronic low level bleeding.

• Perforation

• Gastric outlet obstruction due to chronic scarring at or around the pylorus.

Treatment

General
● Advise to stop smoking,excessive alcohol drinking and NSAIDs.

Medical
1. Reduction of acid secretion-PPI(omeprazole,lansoprazole),H2
Blocker( Ranitidine,Famotidine),Antacid(NaHCO3)
2. Mucosal protective agent(Bismuth,Sucralfate,Misoprostol)
3. H. pylori eradication (mainstay of management in patient with duodenal ulcer)

Triple therapy
Antisecretory agent(PPI) with one or more antibiotics x 7 days followed by a healing dose of
PPI for 4 to 6 weeks.
(Omeprazole or Esomeprazole + Amoxicillin/Clarithromycin/Metronidazole)

Surgical

Rarely necessary with the very highly effective acid-reducing drugs and eradication therapy.
Indications include the following.

● Gastric outlet obstruction

● Failure to respond to maximal medical treatment
● Recurrent or Persistent ulcer
● Suspicious of malignancy in GU
Emergency indications include
• Perforation
• Bleeding

Types of surgery for DU

1. Truncal vagotomy and drainage
2. Truncal vagotomy and antrectomy
3. Highly selective vagotomy
4. Billroth II gastrectomy
Types of surgery for GU
Billroth I gastrectomy

Sequelae of peptic ulcer surgery

There are a number of sequelae of peptic ulcer surgery, which include recurrent ulceration,
small stomach syndrome, bilious vomiting, early and late dumping, diarrhoea and malignant
transformation.