OVERVIEW

Have you ever experienced a dull burning pain in your abdomen, a pain that came when you were hungry or when you had just finished eating a heavy meal?  Not to scare you, but such presentations are common of Peptic Ulcer Disease. Before, we go into detail of what peptic ulcer disease is, it is best to understand the normal function of the organs involved.

The stomach acts as a ‘hopper’ (a funnel-shaped container), where food is further digested by pepsin (protein digesting enzyme) and hydrochloric acid. The stomach is lined with a mucosal layer to prevent damage from the gastric acid and pepsin. The digested food is then transported from the stomach to the duodenum.

In the duodenum, a minute amount of gastric acid is released along with the digested food. Bile, a greenish brown digestive juice and pancreatic enzymes are released from the liver and gallbladder respectively into the duodenum, to ensure the digestion of fats, protein, and carbohydrates in the digested food. The duodenum is also lined with a mucosal layer, to prevent damage from gastric acid and the pancreatic enzymes released.

A peptic ulcer occurs when the mucosal layer of the stomach or duodenum is damaged.

WHAT IS PEPTIC ULCER?

A peptic ulcer is a general term of both gastric ulcer (stomach) and duodenal ulcer(duodenum). This involves an oval or round sore present due the lining of the stomach or duodenum being eroded by stomach acid or digestive juices. The damage can extend to the muscular layer of the stomach or the duodenum, leading to a variety of complications.

It mostly presents with discomfort, which comes and goes, normally occurring after meals. This is due to the production of gastric (stomach) acid when eating.

The damage to the mucosal lining can be due to Helicobacter pylori (a bacterium) infection, drug use or increase in gastric acid.

Types Of Peptic Ulcer

The categories of specific ulcers that fall under peptic ulcer disease are based on their anatomical location and the condition under which they develop.

Below are the forms of ulcers that fall under peptic ulcer disease:

  • Duodenal ulcer:

The most common form of peptic ulcer, which occurs in the duodenum; the first few inches of the digestive canal after the stomach.

  • Gastric ulcer:

Less common and usually present in the lower portion of the stomach.

  • Marginal ulcer:

These develop in parts of the stomach which remains after surgical resection (removal). It is present in the point where the remaining stomach is connected to the intestine.

  • Stress ulcer:

These occur in patients with acute gastritis (inflammation of the stomach). These occur in both the stomach and duodenum. It is normally as a result of stress; (physiological) such as illness, skin burns or injury.

EPIDEMIOLOGY

In sub-Saharan Africa, Sierra Leone and Ivory Coast, there has been an increasing rate of annual deaths from Peptic Ulcer Disease; 13.17% and 10.81%. In Ghana, the current death rate per 100,000 affected individuals is around 6.46%. The gradual rise in stress ulcers and duodenal ulcers is of particular concern in this region.

In contrast, there has been a decrease in the incidence of duodenal ulcers in the United States, over the past few decades. The prevalence of Peptic Ulcer Disease in men has shifted, occurring equally in both men and women. Age has affected ulcer occurrence by revealing a decline in younger men, particularly duodenal ulcer and an increase in older women.

CAUSES

  • Helicobacter pylori infection:

    This curved rod-shaped bacterium is the leading causes of peptic ulcer, due to its characteristic feature of secreting urease and producing ammonia, which provide an alkaline environment suitable for its survival. These chemicals produced by the bacterium injure the digestive tract walls. CagA and PicB which are virulent factors; molecules produced by the bacteria to enable invasion and colonization of the tract, induce mucosal inflammation of either the stomach or duodenum. CagA in particular, is known to also precipitate the development of gastric cancers.

  • NSAIDs:

Non-steroidal Anti-Inflammatory Drugs which are analgesics are common household drugs used to relieve pain (especially among women for menstrual pains). The mechanism of these drugs is by inhibiting the production of prostaglandin E (a key mediator involved in inflammation and tissue defense), stomach mucosal cell proliferation and blood supply to the stomach. The inhibition of these components by NSAIDs makes one susceptible to developing a peptic ulcer.

  • Stress:

Severe physiological stress (not to be confused with emotional stress) like burns and illness, can lead to the release of steroids which inhibit the action of prostaglandin E. Hence, a reduced mucosal defense mechanism.

  • Diet:

The role of diet as a cause of peptic ulcer, has recently been proven to be of a lesser effect than once believed. Alcohol consumption however, together with an H.pylori infection, increases the risk.

PATHOPHYSIOLOGY

The cells of the stomach lining (epithelial cells) secrete mucus (gel-like substance) in response to irritation of the stomach. The cells of the stomach and duodenum also produce bicarbonate (a weak alkali) to neutralize the gastric acid and reduce the acidity. Other inflammatory mediators such as Prostaglandin E aid in the production of bicarbonate and mucus, in protecting the stomach and duodenum.

However, injury occurs when aggressive factors such as NSAIDs (non-steroidal anti-inflammatory drugs), Helicobacter pylori infection, alcohol, bile salts, gastric acid, and pepsin impair the mucosal defense by changing the microenvironment of the stomach to be more acidic or release virulent factors which promote mucosal inflammation.

SIGNS AND SYMPTOMS

Symptoms of peptic ulcer vary with location and the person’s age. Most ulcers are discovered when complications develop.

The most common symptoms include:

  • Recurrent abdominal pain, with minor discomfort, of a burning or dull aching quality. The pain is located typically below the sternum (breastbone).
  • In duodenal ulcer, there is severe pain which awakens the person at night.
  • Pain worsened by food is typical of gastric ulcer.
  • Scarring and swelling of tissues (edema) in gastric ulcers can affect the small intestines causing bloating, nausea or vomiting after eating.
  • Anemia, as a result of bleeding from the ulcers.
  • Melena, a dark black, tarry stool caused by digestion of blood, of upper digestive tract origin.
  • Weight loss.
  • Loss of appetite.

DIAGNOSIS

In order for a health care practitioner to identify peptic ulcer disease, the following investigations are performed:

  • Upper endoscopy: This procedure involves the use of a flexible tube with a camera and light source attached at the end called an endoscope, that is introduced too the digestive tract to determine the cause of ulceration).
  • Biopsy: Removal of a stomach tissue sample for examination under a microscope. This is normally done during an endoscopy.

Other forms of investigation which can be performed are:

  • 13C-urea breath test.
  • Fecal antigen test.
  • Rapid urease tests.
  • Blood gastrin level.

Treatment

In managing peptic ulcer, it is best to observe the following:

  • Avoid smoking and alcohol intake.
  • Avoid foods that worsen the pain.
  • Reduce anxiety and stress.

A health practitioner would recommend the following drugs below to treat peptic ulcer:

  • Antibiotics
  • Acid-reducing drugs:

Proton pump inhibitors are a potent class of drugs that reduce acid production. They promote healing of ulcers in a short period of time as compared to Histamine-2 (H2) blockers. They are also suitable for conditions that cause excessive stomach acid secretion.

Histamine-2 (H2) Blockers also promote healing by reducing stomach acid production. These drugs don’t have serious adverse effects. However, they may cause diarrhea, fever, muscle pain and rash.

  • Antacids: Neutralize acid in the stomach by raising the pH level (alkalinize) in the stomach.

Sodium bicarbonate and Calcium carbonate, are strong antacids which provide fast short-term relief. However, since they are absorbed into the bloodstream, continual use can lead to nausea, headaches, and weakness. This occurs due to prolonged use making the blood is too alkaline.

These drugs are not recommended for patients on a low-salt diet or with high blood pressure.

Aluminum hydroxide is a commonly used antacid which is relatively safe. However, it can bind with phosphate in the digestive tract, hence depleting the body’s calcium and phosphate levels in the blood. This causes general weakness and loss of appetite. A common side-effect of aluminum hydroxide is constipation.

Surgery for ulcers is quite rare because of the efficacy of drugs in healing the condition and endoscopy to prevent bleeding. Most surgeries are done to deal with the complications of peptic ulcer such as:

  • Perforation: a hole in the stomach or duodenum due to the ulcer is life-threatening if left untreated.
  • Obstruction that does not respond to drug treatment.
  • Episodes of bleeding ulcers.
  • Suspected cancerous gastric ulcers.
  • Severe recurrent peptic ulcers.

COMPLICATIONS.

Currently, most peptic ulcers can be cured without complications. However, some cases of peptic ulcer do develop life-threatening complications such as:

  • Bleeding (Hemorrhage):

The most common complication of ulcers. It often presents as vomiting of bright red blood or reddish-brown clumps of partially digested blood (hematemesis). These clumps resemble coffee beans. There is also the passage of black tarry stools (melena) or bright red blood in stool (hematochezia). Significant blood loss can cause weakness, dizziness and a decrease in blood pressure. Anemia can occur if blood loss is persistent.

  • Perforation:

Ulcers present in the duodenum or stomach, can create an opening into the abdominal cavity. The result leads to an intense, sudden and rapidly steady pain through the abdomen. The person may feel the pain in one or both shoulders as well. Deep breaths and changing of position when lying down worsen the pain. When touched, the abdomen feels tender. There is also a characteristic pain, after removal of pressure applied to the abdomen, as opposed to when pressure is directly applied. This is known as rebound tenderness.

  • Obstruction:

Swollen inflamed tissues around an ulcer or scar from a previous ulcer can narrow the outlet of the stomach or the duodenum. Persons with such obstruction may vomit repeatedly, often vomiting large volumes of food eaten in earlier hours. Over time, vomiting can cause weight loss, dehydration and an imbalance in body electrolytes.

  • Cancer:

Patients with a peptic ulcer caused by H. pylori infection are at a high risk of developing cancer. The action of the bacteria in lowering the pH of the microenvironment in the stomach and increasing mucosal inflammation causes gastric metaplasia (change in cell growth). This leads to the development of gastric cancers.