Jeremy

Woodward

Gastroenterologist

crestes70

“In biology, nothing is clear, everything is too complicated, everything is a mess, and just when you think you understand something, you peel off a layer and find deeper complications beneath. Nature is anything but simple.” Richard Preston

Peptic Ulcer

What is Peptic ulceration? 'Peptic' ulcers are breaks in the protective lining of the upper gastrointestinal tract (oesophagus, stomach and duodenum) exacerbated by acid related damage. Duodenal ulcers are four times as common as stomach ulcers. The true prevalence of ulcers is hard to determine as many can be without any symptoms, but about one in ten (10%) of people are thought to experience a peptic ulcer at some stage in their life. The incidence of peptic ulcers is undoubtedly falling due to improvements in general health and hygiene (as usual - rather than advances in medical treatment!).

What causes ulcers? The great majority of duodenal ulcers (90%) and over half (60%) of stomach ulcers are caused by a bacterium called Helicobacter pylori. This is a bacterium that can live in the hostile environment of the stomach. Its discovery in 1982 by two Australians - Barry Marshall and Robin Warren - earned them a Nobel Prize and astonished the medical world by providing an infectious cause for peptic ulceration. The stomach mounts an inflammatory response to the bacterium but is usually unable to clear it, and the inflammation damages the protective mechanisms of the lining, allowing acid to enter the sensitive layers of the stomach and damage it. Even worse, the inflammation leads to an increase in the secretion of a hormone called 'Gastrin' whcih makes the stomach produce even more acid. Helicobacter infection is not easily transmissable and most people are infected in childhood. Infection is generally associated with indicators of social deprivation and is therefore more common in the third world, and is becoming less common with each successive generation in Western countries. Helicobacter causes no problems at all in the majority of patients (80%).
The remainder of peptic ulcers are caused by drugs - particularly agents called 'NSAIDs' - or 'nonsteroidal anti-inflammatory drugs'. These are common substances like Aspirin, Ibuprofen, Diclofenac or Naproxen and are very effective painkillers for rheumatological conditions.
In the stomach, but not the duodenum, ulcers can be associated with cancer - but in only a small proportion of cases (about one in 25).

What symptoms are caused by ulcers? Many ulcers are silent but the typical symptoms are of a gnawing pain in the upper abdomen that may be made better (in the case of stomach ulcers) or worse (after about 2-3 hours in duodenal ulcers) by eating. Ulcers may just cause a sensation of fullness on eating, or nausea or vomiting after eating. Ulcers can bleed, resulting in vomiting of blood or passing altered blood (called 'melaena' because it changes to a black colour) through the bowel. A 'perforated' or 'burst' ulcer is where it has eroded all the way through the wall of the duodenum or stomach and leads to severe infection - peritonitis - of the inside of the abdomen.

How are ulcers diagnosed? The commonest way to diagnose ulcers is by gastroscopy. A test of the lining of the stomach can also be taken at the same time to look for evidence of infection with Helicobacter and in the case of stomach ulcers a biopsy can be taken to make sure that there is no evidence of cancer.

How are ulcers treated? The main treatment for ulcers is the use of acid suppressing medications. These drugs - called 'proton pump inhibitors' (PPI) are very effective at reducing stomach acid and allowing the ulcer to heal. This may take one to two months. If it is very necessary to take aspirin (for instance in someone who has had a heart attack or stroke previously) then the aspirin may be continued with the use of a PPI to protect the stomach. Other NSAIDs should be stopped if possible. If Helicobacter is present it can be treated. This usually requires a combination of antibiotics with a PPI over the course of a week.

Do ulcers come back? Unfortunately, even when the ulcer has healed it can sometimes recur in the same place. Avoiding NSAIDs and aspirin, and making sure that Helicobacter eradication has been successful are ways of preventing ulcers from returning, but this is not always successful.

Are there any complications of peptic ulcers? The most significant and worrying complications of peptic ulceration are gastrointestinal bleeding and perforation. Both of these scenarios are emergencies and require urgent diagnosis and treatment. In the case of bleeding, it is usually possible to stop the bleeding with endoscopic interventions such as injecting adrenaline, placing a metal detachable clip onto the bleeding point to close it off, or cauterising with diathermy current. Perforation usually requires an operation to seal the hole caused by the ulcer and to clean the abdominal cavity from the contamination with intestinal contents.
Ulcers around the pylorus - the exit of the stomach - can lead to scarring that can prevent the passage of solid food and lead to vomiting and weight loss. Similarly, peptic ulcers in the oesophagus can lead to oesophageal narrowing (strictures) that can lead to difficulty swallowing.

You are viewing the text version of this site.

To view the full version please install the Adobe Flash Player and ensure your web browser has JavaScript enabled.

Need help? check the requirements page.


Get Flash Player