PEPTIC ULCER DISEASE (PUD)

PEPTIC ULCER DISEASE (PUD)

Lesions in the stomach or duodenum that extend deeper into the gastrointestinal (GI) tract than other acid-related disorders. These lesions develop in response to damage by gastric acid and pepsin.

Gastric ulcers

occur primarily on the lesser curvature but may occur anywhere in the stomach

pain occurs at any time and may be worsened within eating.

Duodenal ulcers

occur in the first part of duodenum

pain may be worse with an empty stomach (at night or between meals).

Three forms (depending on cause)

Helicobacter pylori (H. pylori)-induced

Nonsteroidal anti-inflammatory drug (NSAID)-induced

Stress-related mucosal damage (SRMD)

H. pylori-induced: condition, site of damage, intragastric pH, symptoms. ulcer depth, GI bleeding

Condition: Chronic

Site of damage: Duodenum > stomach

Intragastric pH: More dependent

Symptoms: Usually epigastric pain

Ulcer depth: Superficial

GI Bleeding: Less severe, single vessel

NSAID-induced

Condition: Chronic

Site of damage: Stomach > duodenum

Intragastric pH: Less dependent

Symptoms: Often asymptomatic

Ulcer depth: Deep

GI Bleeding: More severe, single vessel

SRMD

Condition: Acute

Site of damage: Stomach > duodenum

Intragastric pH: Less dependent

Symptoms: Asymptomatic

Ulcer depth: Most superficial

GI Bleeding: More severe, superficial mucosal capillaries

_{^{SRMD usually starts asymptomatically, but if more acid is produced, it becomes more painful. It’s mostly superficial, that’s why it’s usually managed with Gaviscon to neutralize the acid in combination with esomeprazole (stop acid production).}}

Causes of Peptic Ulcer Disease: rare

• Zollinger-Ellison syndrome

• Malignancy (gastric/lung cancer, lymphomas)

• Stress (Acute illness, burns, head injury)

• Viral infection

• Vascular insufficiency

• Radiation therapy

• Crohn disease

• Chemotherapy

Helicobacter Pylori-Associated PUD

a gram-negative bacillus that is found within the gastric epithelial cells. This bacterium is responsible for 90% of duodenal ulcers and 70% to 90% of gastric ulcers.

Virulence Factors of  Helicobacter Pylori

Urease

Toxins

Flagella

Urease

The secretion of urease breaks down urea into ammonia and protects the organism by neutralizing the acidic gastric environment.

Toxins

CagA/VacA is associated with stomach mucosal inflammation and host tissue damage.

Flagella

Provides motility and allows movement toward the gastric epithelium.

NSAID-associated PUD

is the second most common cause of PUD after H. pylori infection

'‘NSAIDs, corticosteroids, bisphosphonates, potassium chloride, and fluorouracil’

Apart from ‘blank’ have been implicated in the etiology of PUD.

Hypersecretory environment occurs in the following conditions

• Zollinger Ellison syndrome

• Systemic mastocytosis

• Cystic fibrosis

• Hyperparathyroidism

• Antral G cell hyperplasia

Duodenal bulb

Gastric ulcers are most commonly located on the lesser curvature, whereas duodenal ulcers are most common at the ‘blank’

Common signs and symptoms include

• Epigastric abdominal pain

• Bloating

• Abdominal fullness

• Nausea and vomiting

• Weight loss/weight gain

• Hematemesis

• Melena

Warning symptoms or alarm symptoms that should prompt urgent referral include

• Unintentional weight loss

• Progressive dysphagia

• Overt gastrointestinal bleeding

• Iron deficiency anemia

• Recurrent emesis

• Family history of upper gastrointestinal malignancy

Common with duodenal ulcers symptom

Nocturnal pain

Weight loss

The pain of gastric ulcers increases 15 to 30 minutes after a meal and may result in ‘blank’

Weight gain

the pain of duodenal ulcers decreases with a meal, which can result in ‘blank’

further investigated

Any patient presenting with anemia, melena, hematemesis, or weight loss should be ‘blank’ for complications of PUD

Esophagogastroduodenoscopy (EGD)

Gold standard and most accurate diagnostic test with sensitivity and specificity up to 90% in diagnosing gastric and duodenal ulcers.

Barium swallow

It is indicated when EGD is contraindicated

Investigations

Esophagogastroduodenoscopy (EGD)

Barium swallow

Complete blood work, liver function, and levels of amylase and lipase

Serum gastric is ordered if Zollinger-Ellison syndrome is suspected

Helicobacter pylori testing

Computerized tomography of the abdomen with contrast is of limited value in the diagnosis of PUD itself but is helpful in the diagnosis of its complications like perforation and gastric outlet obstruction