Peptic Ulcer Disease (Duodenal Ulcer: Gastric Ulcer)
 Definition
This term describes both stomach and duodenal ulcers, whose symptoms are very
similar.
Incidence/Age/Sex
Gastric or stomach ulcers used to be more common in the early 1900s and are becoming
less frequent. Duodenal ulcers, that is ulcers of the first part of the intestine
leading out of the stomach are much more common. Duodenal ulcers are two to three
times commoner than gastric ulcers and around 10 - 15% of the population will
suffer with them. They are four or five times more likely to occur in men than
women. Both gastric and duodenal ulcers are more common in older people. Duodenal
ulcers are also more common in the North of England and Scotland.
Causes/Prevention
Ulcers occur when the caustic gastric juices which contain acid and enzymes to
help break down the food (pepsin) break through the defences to attack the lining
of the stomach. The stomach contains a mucus, bicarbonate and other substances
which help to protect the stomach lining. It is now known that a bacterium called
Helicobacter pylori has an important role in promoting both gastric and duodenal
ulcers although we are not sure why. It is possible that infection with this bacterium
causes an increase in the amount of acid in the stomach or it causes an alteration
in the protective mucus layer. Acid secretion is increased by Helicobacter pylori
when it stimulates a hormone called gastrin which itself promotes acid secretion.
Helicobacter pylori is found in around 90 - 95% of duodenal ulcer patients and
around 70% of gastric ulcer patients.
Patients with peptic ulcers often have a family history of the disease and most
people with Blood Group O have more ulcers than those with other blood groups.
Gastric and duodenal ulcers are also found more commonly in people taking non-steroidal
anti-inflammatory drugs, such as Aspirin,
Ibuprofen, Diclofenac and other drugs used for pain relief and the treatment of inflammation
in arthritis. Steroid tablets may contribute to the development of ulcers, but
diet, stress and alcohol are important.
Signs and Symptoms
Indigestion is the classic symptom and pain in the epigastrium (the top part
of the abdomen just below the ribs in the centre of the abdomen) is frequent.
Pain is often worse at night when the patient is hungry and may be accompanied
by nausea. Self treatment with antacid tablets and liquid is common and causes
temporary relief from pain. Most people with a duodenal and/or gastric ulcer
which heals will have a relapse within one or two years.
Complications
Gastric and duodenal ulcers can perforate or bleed. Perforation occurs when
the ulcer becomes so deep that the entire thickness of the stomach or duodenum
is worn away and the stomach or duodenal contents can leak into the surrounding
abdomen. This causes severe persistent pain. Bleeding from duodenal and gastric
ulcers may occur if an underlying artery is eroded and when this happens a patient
may vomit blood (haematemesis) which may look like fresh red blood or may look
rather black like coffee-grounds. Alternatively, the blood may pass through
the gut and become changed so that the motions or stools become tarry black
and sticky with a characteristic smell. Both perforation and bleeding from ulcers
can be life threatening.
Diagnostic Tests
When a duodenal or gastric ulcer is suspected the common test performed is that
of gastroscopy which allows direct visualization of the stomach and duodenal
lining.
Gastroscopy - This test is
performed with a thin flexible tube containing a fibre optic light source with
a video camera at the top end. A tube is passed through the mouth and down the
oesophagus or gullet into the stomach and from there into the duodenum. Air
is passed into the stomach to inflate it and the lining is inspected by way
of a video screen. Ulcers can be viewed and specimens taken at the same time.
If an ulcer is seen, then it is common to take a small pinch of the stomach
lining (a biopsy) to look for Helicobacter pylori, the bacterium implicated
in peptic ulcer disease.
Treatment
Medical
Drug treatment of duodenal ulcer disease:
- Simple antacids such as sodium bicarbonate, Aluminium Hydroxide, Calcium
Carbonate, and Magnesium compounds are all available in tablet and liquid
form from Pharmacists and Supermarkets and provide short term relief from
acid indigestion.
- H2 receptor antagonists - These have been available for over 20 years and
produce about 80% reduction in acid secretion by the stomach and will heal
most ulcers within 8 weeks.
- Proton pump inhibitors - These are extremely effective suppressors of acid
production giving
90% inhibition of acid throughout a 24 hr period and heal most ulcers within
4 weeks.
Omeprazole, Lansoprazole and Rabeprazole are commonly used.
- Misoprostol - A prostoglandin analogue is a protective agent which inhibits
acid
secretion and promotes ulcer healing. This drug is usually used in people
taking non-steroidal
anti-inflammatory drugs such as Ibuprofen and it is generally used as a preventative
measure
rather than an ulcer healing measure.
- Mucosal protection agents, such as Sucralfate are now only rarely used.
Helicobacter eradication treatment
Since most ulcers are associated with Helicobacter pylori and most ulcers will
relapse after healing if only acid reducing therapy is given, it is now common
to give patients a course of triple therapy to try to eradicate the Helicobacter
pylori organism from the stomach. Triple therapy usually consists of two antibiotics
plus an acid reducing tablet. The most common combination is that of
Amoxycillin, Metronidazole and a proton pump inhibitor such as
Omeprazole or Lansoprazole.
Clarithromycin is an antibiotic which is used instead of
Amoxycillin when patients are penicillin allergic.
Surgical Treatment
Surgery used to be very common for duodenal and gastric ulcers but now is usually
reserved for the complications of ulcers, such as perforation or bleeding. The
trend is towards minimal surgery with over sewing of a hole or bleeding point
rather than removal of all or part of the stomach and first part of the duodenum.
Surgery is sometimes used when ulcers are frequently recurring and when the
gastric outlet is scarred and deformed so that the stomach is unable to empty
properly. This condition is called pyloric stenosis and can lead to severe vomiting.
In this case, part of the stomach is removed and the intestine is then joined
to the stomach remnant.
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