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Peptic ulcer

A peptic ulcer is a defect in the lining of the stomach (gastric ulcer) or the initial portions of the duodenum (duodenal ulcer) that extends beyond the muscle plate. Almost all ulcers are caused by Helicobacter pylori bacteria or NSAIDs. Typical symptoms include burning epigastric pain that usually goes away after eating. Diagnosis is by endoscopy and Helicobacter pylori analysis . Treatment includes suppressing acid production, eradicating H. pylori (if present), and eliminating the negative effects of NSAIDs.

Etiology

  1. pyloriand NSAIDs interfere with the normal defense and repair of the mucous membrane, making it more sensitive to acid. H. pylori is present in 50–70% of patients with duodenal ulcer and in 30–50% of patients with gastric ulcer. After elimination of H. pylori infection, recurrence of peptic ulcer disease occurs in only 10% of cases, compared with 70% of relapses in patients who received treatment aimed only at suppressing acid production. NSAIDs now account for>; 50% of peptic ulcers.

Smoking is a risk factor for the development of ulcers and their complications. Smoking also interferes with ulcer healing and increases relapse rates. The risk increases with the number of cigarettes smoked per day. Although alcohol serves as a strong stimulant for acid secretion, there is no definite relationship between small amounts of alcohol and ulceration or delayed healing. A very small number of patients have gastrin hypersecretion caused by gastrinoma (Zollinger-Ellison syndrome).

50-60% of children with duodenal ulcers have a burdened family history.

Clinical manifestations

Symptoms depend on the location of the ulcer and the age of the patient; a large number of patients, especially the elderly, have few or no symptoms. The most common pain is pain, often localized in the epigastrium and relieved by eating or antacids. The pain is described as burning or gnawing, sometimes as hungry. The disease has a chronic and recurrent course. Only half of the patients have characteristic symptoms.

Symptoms of a stomach ulcer are often not permanent (eg, eating sometimes increases rather than alleviates pain). This is true for pyloric canal ulcers, which are often associated with stenotic symptoms (eg, bloating, nausea, vomiting) caused by edema and scar tissue.

Duodenal ulcers tend to have more persistent pain. The pain is absent when the patient wakes up, arises in the middle of the morning and is relieved with food, but returns 2-3 hours after eating. The pain from which the patient wakes up at night is a common symptom of duodenal ulcers, which should be considered as evidence of this disease. In newborns, perforation and bleeding can be a manifestation of a duodenal ulcer. Bleeding may also be the first recognized sign in young children, although repeated vomiting or abdominal pain may be clues to the diagnosis.

Diagnostics


  • Endoscopy
  • Sometimes serum gastrin levels

The diagnosis of peptic ulcer can be suspected based on the history and confirmed by endoscopy. Empiric therapy is often started before a definite diagnosis is established. However, the endoscopy procedure allows you to take a biopsy or cytological scraping with a brush from the affected areas of the stomach and esophagus to differentiate between simple ulcers and ulcerative gastric cancer. Stomach cancer may present in a similar manner and should be ruled out, especially in patients>; 45 years of age, in patients with weight loss, or who report severe and refractory symptoms. The incidence of malignant duodenal ulcers is extremely low, so a biopsy of a duodenal ulcer is generally not warranted.  Gastrin-producing tumors and gastrinomas should be suspected in the presence of multiple ulcers, if ulcers are atypical (eg, postbulbar), if they are refractory to treatment, or if there is significant diarrhea and weight loss. In such patients, serum gastrin levels should be determined.

Penetration (limited perforation)

A peptic ulcer can penetrate the stomach wall. If adhesion prevents leakage into the peritoneal cavity, then open penetration does not occur, but limited perforation occurs. In addition, the ulcer can penetrate into the duodenum and enter an adjacent confined space (bursa) or other organs (eg, pancreas, liver). The pain can be intense, constant, radiating outside the abdomen (usually to the back, if the pain is caused by the penetration of the ulcer of the posterior duodenal wall into the pancreas) and changes with changes in body position. Usually, CT and MRI are needed to confirm the diagnosis. In the absence of the effect of conservative treatment, surgical treatment is required.

Free perforation

Ulcers that invade the peritoneal cavity without being limited by adhesion are usually located on the anterior wall of the duodenum or less commonly the stomach. The clinical picture of an acute abdomen develops. Epigastric pain is sudden, intense, prolonged, quickly spreads over the abdomen, often becoming pronounced in the right lower quadrant, sometimes radiating to one or both shoulders. Usually the patient lies motionless because even deep breathing increases the pain. You can buy aciphex for treat. Palpation of the abdomen is painful, peritoneal symptoms are expressed, the muscles of the abdominal wall are tense (like a plaque), intestinal sounds are reduced or absent. The diagnosis is confirmed if free air is found under the diaphragm or in the abdominal cavity on x-ray or CT. An upright chest and abdominal x-ray is preferred. The most informative is a lateral x-ray examination of the chest. In critically ill patients, it may not be possible to perform abdominal fluoroscopy while sitting upright, and in this case, the study should be performed in a lateral decubital position. The lack of free air does not exclude the diagnosis.

Immediate surgery is required. The longer it is delayed, the worse the prognosis. It is necessary to prescribe intravenous antibiotics that are active against the intestinal microflora (for example, cefotetan or amikacin in combination with clindamycin). Typically, NGZ is used when continuous nasogastric tube aspiration is required. In those rare cases when the operation cannot be performed, a poor prognosis develops.

Pyloric obstruction

The narrowing can be caused by scarring, spasm, or inflammation associated with an ulcer. Symptoms include recurrent high-volume vomiting, more frequently at the end of the day and 6 hours after the last meal. Loss of appetite with persistent bloating or fullness after eating is also common with gastric outlet stenosis. Prolonged vomiting can cause weight loss, dehydration, and alkalosis.

If history suggests stenosis, physical examination, gastric aspiration, or x-ray can confirm gastric retention. A splashing noise heard more than 6 hours after a meal, or aspiration of fluid and food debris >; 200 ml after overnight fasting suggests gastric retention. If gastric aspirate shows significant delay, the stomach should be emptied and endoscopy or x-ray performed to determine the location, cause, and extent of the obstruction.