Track 16: Peptic Ulcer Disease

Peptic Ulcer Disease (PUD) is a condition characterized by the development of ulcers or sores in the lining of the stomach (gastric ulcer) or the duodenum (the first part of the small intestine) (duodenal ulcer). These ulcers form when the protective mucosal layer in the digestive tract becomes damaged due to an imbalance between the factors that protect the stomach lining and those that promote the production of gastric acid.

Peptic ulcers are common and can affect people of all ages. If left untreated, PUD can lead to serious complications such as bleeding, perforation (a hole in the stomach or intestinal wall), and gastric obstruction.

Causes of Peptic Ulcer Disease

Helicobacter pylori Infection

One of the most common causes of PUD is an infection with the bacterium Helicobacter pylori (H. pylori). H. pylori damages the protective mucous layer of the stomach lining, making it more susceptible to the corrosive effects of stomach acid.

H. pylori infection is usually acquired in childhood, and many people carry the bacteria without developing symptoms. However, in some people, the bacteria lead to chronic inflammation of the stomach lining, increasing the risk of ulcer formation.

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

Long-term use of NSAIDs, such as ibuprofen, aspirin, and naproxen, is another major cause of peptic ulcers. NSAIDs inhibit the production of prostaglandins, substances that help maintain the protective mucosal barrier in the stomach. This makes the stomach lining more vulnerable to damage from stomach acid.

People who take high doses of NSAIDs over a long period or those who combine NSAIDs with alcohol or smoking are at greater risk of developing ulcers.

Excessive Alcohol Consumption

Excessive alcohol intake can irritate and erode the stomach lining, increasing the risk of ulcer formation. Alcohol can also impair the healing of existing ulcers.

Smoking

Smoking increases the production of stomach acid and decreases the production of bicarbonate, which neutralizes stomach acid. It also impairs the healing of ulcers and increases the risk of complications like bleeding and perforation.

Stress

While stress is not directly responsible for causing peptic ulcers, it can exacerbate symptoms in people who are already at risk. Severe physical stress (e.g., due to trauma, surgery, or burns) can also lead to stress ulcers, which are ulcers that form in critically ill patients.

Genetic Factors

A family history of peptic ulcers may increase the likelihood of developing the condition. Genetic predisposition, along with environmental factors like smoking, drinking, and diet, may contribute to ulcer formation.

Other Factors

Conditions such as Zollinger-Ellison syndrome, which leads to excessive acid production, can also result in peptic ulcers.

Symptoms of Peptic Ulcer Disease

The symptoms of PUD can vary depending on the location of the ulcer and its severity. Some common symptoms include:

Abdominal Pain

The most common symptom is a burning or gnawing pain in the upper abdomen. The pain may occur 2-3 hours after eating or during the night. It is often relieved by eating food or taking antacids but can return once the stomach empties.

Nausea and Vomiting

People with peptic ulcers may experience nausea or vomiting, particularly if the ulcer is associated with delayed stomach emptying or complications like bleeding.

Bloating and Belching

Bloating and frequent belching may occur due to gastric discomfort and indigestion associated with ulcers.

Loss of Appetite and Weight Loss

Some people with peptic ulcers experience a loss of appetite, which can lead to unintentional weight loss.

Heartburn

Peptic ulcers can cause acid reflux or heartburn, especially if the ulcer is located in the stomach or the lower esophagus.

Complications of Peptic Ulcer Disease

Bleeding

One of the most serious complications of PUD is bleeding. The ulcer may erode into blood vessels, leading to internal bleeding. This can result in symptoms like vomiting blood (which may appear as dark or coffee-ground material), black, tarry stools, or anemia (low red blood cell count).

Perforation

A perforated ulcer is a life-threatening condition where the ulcer creates a hole in the stomach or intestinal wall, allowing stomach acid and contents to leak into the abdominal cavity. This can lead to peritonitis, a severe infection of the abdominal lining, which requires emergency treatment.

Gastric Outlet Obstruction

Chronic peptic ulcers, especially those in the duodenum, can lead to gastric outlet obstruction. This occurs when swelling or scarring from the ulcer blocks the passage of food from the stomach into the small intestine, causing nausea, vomiting, and difficulty eating.

Cancer

Although rare, gastric cancer can develop as a complication of chronic peptic ulcers, especially in the presence of H. pylori infection, which is considered a risk factor for gastric cancer.

Diagnosis of Peptic Ulcer Disease

Endoscopy

The most definitive diagnostic test for PUD is upper gastrointestinal endoscopy (EGD). During this procedure, a flexible tube with a camera is inserted through the mouth to directly visualize the stomach and duodenum. The doctor can also take biopsies to check for H. pylori infection or other abnormalities.

Tests for H. pylori

If H. pylori infection is suspected, doctors may use one of the following tests:

Breath test: The patient drinks a liquid containing urea, and if H. pylori is present, the bacteria will break down the urea and release carbon dioxide, which can be detected in the breath.

Blood test: A blood test can detect antibodies to H. pylori, but it cannot differentiate between past and current infection.

Stool antigen test: This test detects H. pylori antigens in the stool.

Barium Swallow

In some cases, a barium swallow (X-ray imaging after ingesting a contrast agent) may be used to look for ulcers or other abnormalities in the upper GI tract.

Other Laboratory Tests

If bleeding or anemia is suspected, blood tests may be done to check for low hemoglobin levels, increased white blood cell count (which can indicate infection), or other signs of complications.

Treatment of Peptic Ulcer Disease

The treatment of PUD depends on the underlying cause, the severity of symptoms, and the presence of complications.

Antibiotics for H. pylori Infection

If an H. pylori infection is diagnosed, a combination of antibiotics (such as clarithromycin, amoxicillin, or metronidazole) is used to eradicate the bacteria. This is typically combined with proton pump inhibitors (PPIs) or H2-receptor antagonists to reduce stomach acid production.

Proton Pump Inhibitors (PPIs)

PPIs (e.g., omeprazole, lansoprazole) are the most common medications used to treat PUD. They work by reducing the production of stomach acid, allowing the ulcer to heal and preventing further damage.

H2-Receptor Antagonists

H2 blockers (e.g., ranitidine, famotidine) are another class of medications that reduce stomach acid production, but they are less potent than PPIs.

Antacids and Antisecretory Drugs

Over-the-counter antacids (such as Tums or Maalox) can be used to neutralize stomach acid and relieve mild symptoms of heartburn and discomfort.

Misoprostol may be used to prevent NSAID-induced ulcers, as it helps protect the stomach lining.

Discontinuing NSAIDs and Alcohol

Patients with NSAID-induced ulcers should discontinue the use of NSAIDs and switch to alternative pain management strategies. Limiting or avoiding alcohol is also essential for ulcer healing.

Surgical Treatment

In severe cases, such as when there is perforation, bleeding, or gastric outlet obstruction, surgery may be required to repair the ulcer or remove the affected part of the stomach or duodenum.

Prevention of Peptic Ulcer Disease

Avoid Excessive NSAIDs

Limit the use of NSAIDs and consider alternatives for pain management, such as acetaminophen, which does not irritate the stomach lining.

Avoid Alcohol and Smoking

Limiting alcohol consumption and quitting smoking can reduce the risk of developing ulcers and promote healing in individuals with existing ulcers.

Healthy Diet

While there is no specific ulcer diet, consuming a balanced diet with plenty of fruits, vegetables, and whole grains can promote overall gut health and reduce irritation of the stomach lining.

Treating H. pylori Infection

Early detection and treatment of H. pylori infection can reduce the risk of ulcer formation and prevent recurrence.

Stress Management

Managing stress through relaxation techniques, exercise, and healthy coping mechanisms may help reduce the risk of ulcer formation and exacerbate existing symptoms.

Conclusion

Peptic Ulcer Disease is a common and treatable condition that can cause significant discomfort and lead to serious complications if left untreated. The most common causes of PUD are H. pylori infection and the long-term use of NSAIDs, with other factors like alcohol, smoking, and stress also contributing. With appropriate treatment, including the use of antibiotics, acid-reducing medications, and lifestyle modifications, most people with PUD can heal successfully and prevent recurrence.