Peptic ulcer

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1- Introduction

2- Pathophysiology

3- Symptoms

4- Treatment

Introduction

A peptic ulcer is a break, or an ulceration, in the protective mucosal lining of the lower esophagus, stomach, or duodenum. Approximately 14.5 million people in the United States have peptic ulcer disease. Two major risk factors for peptic ulcer disease are H. pylori infection of the gastric mucosa and habitual use of NSAIDs. Alcohol and smoking may influence susceptibility to ulcer disease. Some chronic diseases, such as emphysema, rheumatoid arthritis, and cirrhosis, are associated with the development of peptic ulcers. Psychological stress may be a risk factor for peptic ulcer disease, although studies of life stress and ulcer disease are inconclusive. The exact mechanism of causation is not known.

Pathophysiology

Gastric mucosal infection with H. pylori is a major cause of peptic ulcers. Chronic use of NSAIDs suppresses mucosal prostaglandin synthesis resulting in decreased bicarbonate secretion and mucin production, and increased secretion of hydrochloric acid. The interaction of NSAIDs and H. pylori in the pathogenesis of peptic ulcer is not clear. Disruption of the mucosa exposes submucosal areas to gastric secretions and autodigestion, causing erosion and ulceration.

Symptoms

  • Burning pain: This is the most common symptom, typically felt between the navel and the breastbone, often occurring when the stomach is empty and may be relieved by eating or taking antacids.
  • Nausea and vomiting: Especially if the ulcer is located in the stomach.
  • Feeling bloated or full: This can occur shortly after eating.
  • Belching: Especially if it provides relief from the discomfort.
  • Loss of appetite: Due to pain or discomfort after eating.
  • Unexplained weight loss: Can occur in severe cases.
  • Dark or black stools: Indicating bleeding from the ulcer.
  • Vomiting blood: A severe symptom indicating significant bleeding from the ulcer.

Treatment

Medications

  1. Proton Pump Inhibitors (PPIs):

    • Reduce stomach acid production and promote healing of the ulcer. Examples include omeprazole, lansoprazole, and esomeprazole.

  2. H2-receptor antagonists:

    • Reduce acid production in the stomach. Examples include ranitidine, famotidine, and cimetidine.

  3. Antibiotics (if H. pylori infection is present):

    • Combination therapy with antibiotics such as amoxicillin, clarithromycin, metronidazole, and others to eradicate H. pylori bacteria.

  4. Cytoprotective agents:

    • Help protect the lining of the stomach and duodenum. Examples include sucralfate and misoprostol.

Lifestyle Modifications

  1. Avoiding NSAIDs and other irritants:

    • Stop using nonsteroidal anti-inflammatory drugs (NSAIDs) or switch to alternatives that are less likely to irritate the stomach lining.

  2. Dietary changes:

    • Avoiding spicy foods, caffeine, alcohol, and other foods that may aggravate symptoms.

  3. Smoking cessation:

    • Quit smoking, as smoking can delay ulcer healing and increase the risk of complications.

Procedures and Surgery

  1. Endoscopy:

    • Used to diagnose the ulcer and sometimes to treat it directly by injecting medication, applying clips, or performing other interventions.

  2. Surgery:

    • Rarely needed, but may be necessary for ulcers that don’t heal with medication, or if complications like perforation or bleeding occur.

Monitoring and Follow-up

  • Regular follow-up with a healthcare provider to monitor healing and ensure that the treatment is effective.
  • Testing for H. pylori infection after treatment to confirm eradication if antibiotics were prescribed.
  • Long-term management may involve periodic use of medications to prevent recurrence, especially if NSAIDs cannot be avoided.

Complications

  • Bleeding: May require endoscopic treatment or surgery.
  • Perforation: Requires emergency medical attention and surgical intervention.
  • Obstruction: Rarely, ulcers can lead to blockages in the digestive tract.
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