Peptic ulcer overview: Difference between revisions
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===Laboratory Findings=== | ===Laboratory Findings=== | ||
There is no specific diagnostic laboratory test for [[peptic ulcer disease]] but in the patient with the history of [[peptic ulcer disease]], the laboratory test is used to rule out [[bleeding]] and to document the status of eradication therapy and to test refractory [[ulcers]]. | |||
===Imaging Findings=== | ===Imaging Findings=== |
Revision as of 21:25, 3 December 2017
Peptic ulcer Microchapters |
Diagnosis |
---|
Treatment |
Surgery |
Case Studies |
2017 ACG Guidelines for Peptic Ulcer Disease |
Guidelines for the Indications to Test for, and to Treat, H. pylori Infection |
Guidlines for factors that predict the successful eradication when treating H. pylori infection |
Guidelines to document H. pylori antimicrobial resistance in the North America |
Guidelines for evaluation and testing of H. pylori antibiotic resistance |
Guidelines for when to test for treatment success after H. pylori eradication therapy |
Guidelines for penicillin allergy in patients with H. pylori infection |
Peptic ulcer overview On the Web |
American Roentgen Ray Society Images of Peptic ulcer overview |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ;Associate Editor(s)-in-Chief: Manpreet Kaur, MD [2]
Overview
A peptic ulcer'[1] is an ulcer of an area of the gastrointestinal tract that is usually acidic and thus extremely painful. 80% of ulcers are associated with Helicobacter pylori, a spiral-shaped bacterium that lives in the acidic environment of the stomach, however only 20% of those cases go to a doctor (for it is not a dangerous case if caught in time and can be treated with surgery). Ulcers can also be caused or worsened by drugs such as Aspirin and other NSAIDs. Contrary to general belief, more peptic ulcers arise in the duodenum (first part of the small intestine, just after the stomach) than in the stomach. About 4% of stomach ulcers are caused by a malignant tumor, so multiple biopsies are needed to make sure. Duodenal ulcers are generally benign.
Historical Perspective
In 16th, 17th century, 18th and 19th centuries, there is evidence of chapters on the peptic ulcer disease by Smith, Rivers, and Goldstein. 100 years ago, Polish Clinical Researcher Professor W.Jaworski first to describe spiral-shaped microorganism at Cracow Jagiellonian University but was confirmed in the animal by G.Bizzazero.Asklepios was the first to describe an association between GI bleeding and peptic ulcer disease.In 1982 Warren and B.J marshall cultured the organism and found a strong association between Helicobacter pylori and inflammation of gastric mucosa, not due to spicy food and stress and awarded the noble prize.
Classification
Peptic ulcer disease may be classified into two types based on the location, gastric ulcer and duodenal ulcer. Gastric ulcers are present mostly at lesser curvature of the stomach. Duodenal ulcers are mostly present at the duodenal bulb.
Pathophysiology
A major causative factor (60% of gastric and 90% of duodenal ulcers) is chronic inflammation due to Helicobacter pylori that colonize the antral mucosa. The immune system is unable to clear the infection, despite the appearance of antibodies. Thus, the bacterium can cause a chronic active gastritis (type B gastritis), resulting in a defect in the regulation of gastrin production and gastrin secretion is increased. Gastrin stimulates the production of gastric acid by parietal cells. The acid erodes the mucosa and causes the ulcer. Another major cause is the use of NSAIDs The gastric mucosa protects itself from gastric acid with a layer of mucus, the secretion of which is stimulated by certain prostaglandins. NSAIDs block the function of cyclooxygenase 1 (cox-1), which is essential for the production of these prostaglandins.
Causes
Common causes of peptic ulcer disease include Helicobacter pylori infection and NSAID use. Less common causes of peptic ulcer disease include Crohn's disease, Zollinger-Ellison syndrome, Cushing and Curling ulcers, Carcinoid tumors, and carcinoid syndrome.
Differentiating Peptic ulcer overview from Other Diseases
Peptic ulcer disease must be differentiated from other causes of acute upper gastrointestinal bleeding such as esophageal varices, Mallory-Weiss syndrome, gastrointestinal cancer, arteriovenous malformations, esophagitis, and esophageal ulcer. Peptic ulcer disease must also be differentiated from gastroesophageal reflux disease (GERD,pancreatitis, Zollinger-Ellison Syndrome,cholelithiasis,gastric outlet syndrome,myocardial infaraction ,pleural empyema and appendicitis.
Epidemiology and Demographics
The incidence and prevalence of Helicobacter pylori infection are generally higher among people born outside North America. Within North America, the prevalence of the infection is higher in certain racial and ethnic groups, and people who have immigrated to North America.Peptic ulcer disease is acquired during childhood.The incidence of Peptic ulcer disease increases with age; the median age at diagnosis is 18-30 years.Peptic ulcer disease affect equally in childhood.Men are more commonly affected by peptic ulcer disease than women in adulthood.
Risk Factors
Common risk factors in the development of peptic ulcer disease include infection from Helicobacter pylori, chronic use of NSAIDs, cigarette smoking, alcolhol intake, family history of peptic ulcer, and age >50 years.Less common risk factors in the development of peptic ulcer disease include psychological stress, nosocomial stress ulcers, and coagulopathy.Rare conditions associated with gastric acid hypersecretion, such as zollinger-ellison syndrome, mastocytosis, or a retained antrum following partial gastrectomy gastrinoma or multiple endocrine neoplasia types I (MEN-I), antral G cell hyperplasia, basophilic leukemias, short bowel syndrome.
Screening
According to the American Society of Gastroenterology, screening for the Peptic Ulcer Disease is not recommended.
Natural History, Complications, and Prognosis
Natural History
Peptic ulcers tend to come back if untreated. Cure rates are high and recurrence is low, if patient is compliant to treatment.
Complications
Prognosis
Prognosis is good if the eradication therapy of Helicobacter pylori is taken.The recurrence rate of patients with peptic ulcer disease is less than 20%.
Diagnosis
Diagnostic Criteria
History and Symptoms
Physical Examination
Laboratory Findings
There is no specific diagnostic laboratory test for peptic ulcer disease but in the patient with the history of peptic ulcer disease, the laboratory test is used to rule out bleeding and to document the status of eradication therapy and to test refractory ulcers.
Imaging Findings
If a peptic ulcer perforates, air will leak from the inside of the gastrointestinal tract (which always contains some air) to the peritoneal cavity (which normally never contains air). This leads to "free gas" within the peritoneal cavity. If the patient stands erect, as when having a chest X-ray, the gas will float to a position underneath the diaphragm. Therefore, gas in the peritoneal cavity, shown on an erect chest X-ray or supine lateral abdominal X-ray, is an omen of perforated peptic ulcer disease.
An esophagogastroduodenoscopy (EGD), a form of endoscopy, also known as a gastroscopy, is carried out on patients in whom a peptic ulcer is suspected. By direct visual identification, the location and severity of an ulcer can be described. Moreover, if no ulcer is present, EGD can often provide an alternative diagnosis.
Other diagnostic studies
Testing of H.pylori infection is very important for treating ulcers.H.pylori tested by 2 methods : invasive and non-invasive.Rapid urease testing is invasive test which is used as diagnostic study of choice.Stool monoclonal antigen test is one of the non-invasive test which is used to diagnose active infection.
Treatment
Medical Therapy
Peptic ulcer disease is the cause of dyspepsia in about 10% of patients. 95% of duodenal and 70% of gastric ulcers are associated with Helicobacter pylori.Eradication of Helicobacter pylori with antimicrobial agents is indicated for patients with gastric or duodenal peptic ulceration, who are colonized with H. pylori, and patients with MALT lymphoma. Eradication therapy should also be considered in patients with immune thrombocytopenic purpura who are H. pylori-positive and patients who have undergone resection for early-stage gastric cancer. Pharmacologic therapies for peptic ulcer disease due to H. pylori is either triple or quadruple pharmacologic agents that include a Proton pump inhibitors plus a combination of antimicrobial agents. The use of antimicrobial therapy is discouraged among asymptomatic carriers.
Surgery
Surgery for peptic ulcer is indicated for bleeding and perforated peptic ulcer.Bleeding ulcers are usually treated first with endoscopic therapy but if they bleed after endoscopic therapy, surgery is done to control bleeding. Perforated peptic ulcer is an emergency, immediate laparoscopic closure of ulcer is done.
Prevention
Helicobacter pylori eradication has been proved as the most cost-effective strategy for primary prevention of NSAID-associated peptic ulcer, especially for patients above the age of 50 years
References
- ↑ "GI Consult: Perforated Peptic Ulcer". Retrieved 2007-08-26.