Ulcers, All You Need To Know About Peptic Ulcers

The linings of the stomach and intestines, may be eroded by acid, released in the stomach, and by chemicals like aspirin and strong alcohol. When erosions are deep enough (to involve the deeper layers), the lesions are called ulcers.

An ulcer caused by (stomach) acid injury, is called Peptic Ulcer.

If the ulcer is located in the duodenum, it is called Duodenal ulcer.

If the ulcer is located in the stomach lining itself, it is called Gastric ulcer.

SYMPTOMS OF STOMACH AND DUODENAL ULCERS
Ulcers are painful sores, which are felt as pain in the abdomen. The symptoms include:

Discomfort or pain (especially at night) in the upper belly, Pain improves after eating.

Feeling full, as soon as one starts to eat.
Nausea
Bloating and Abdominal fullness.
RISK FACTORS FOR ULCERS:
Ulcers develop, because of the following reasons.
a.) An Increase in acid production in the stomach
b.) A decrease in the production of the protective mucus and bicarbonate in the stomach.

c.) A third mechanism is direct irritation of the lining, as seen with, Alcohol consumption.

1.) Factors promoting acid production include:

. Stomach Infection with the bacteria, called Helicobacter pylori (H. Pylori) and

. Nicotine(tobacco)
2.) Factors that reduce mucus (and bicarbonate) production in the stomach:

Prostaglandins: influence, positively, mucus and bicarbonate secretions in the stomach.

Prostaglandins depleting agents like Aspirin and NSAIDs (ibuprofen, phenylbutazone, naproxen) make the stomach linings, more susceptible to injury.

A few details on these factors and agents:
HELICOBACTER PYLORI
Helicobacter pylori stomach infection. H. pylori was discovered in 1982, as the bacteria that increases acid production in the stomach. H pylori infection in the stomach, is the leading cause of Peptic ulcers in our parts of the world.

Transmission:
. Person to person through vomitus, and stools.
. Through drinking untreated and contaminated water.

Humans are the main reservoir (>50 % of world population have this chronic infection).

Poor hygiene and crowded conditions favor transmission.

Most people acquired the infection, in early childhood.

ASPIRIN
Aspirin is used regularly for migraine headaches, Joint pain and for clot prevention and heart protection.

Aspirin blocks protective mucus production in the stomach by impeding prostaglandin synthesis. Prostaglandins increase mucus and bicarbonate production in the stomach.

Aspirin is one of the major causes of peptic ulcers. The risk for aspirin use leading to ulcer formation and bleeding ulcers include:

. Old age, especially elderly persons.
. A previous history of peptic ulcer
. The presence of H. pylori bacteria in the stomach

NSAIDs like Ibuprofen, phenylbutazone, Naproxen (like aspirin, disrupt protective stomach mucus production by blocking prostaglandins production).

Tobacco use (Nicotine stimulates acid production and simultaneously, reduces protective mucus production in the stomach)

Alcohol :strong alcoholic beverages do irritate the stomach lining.

COMPLICATIONS OF PEPTIC ULCERS
Ulcers may Bleed.
Ulcers Create a hole in the stomach wall(Perforation)

Ulcers Erode into other organs near the stomach including liver, pancreas and intestines (Penetration)

Ulcers may swell and prevent the emptying of stomach and duodenal content (Obstruction)

Bleeding peptic ulcers: Bleeding may be acute, and manifests as upper belly pain associated with blood in vomitus and/or dark stools and dizziness from decrease in blood pressure.

Chronic peptic ulcer bleeds present as iron deficiency anemia. A Bleed from stomach and intestines must always be suspected, if a male, or a postmenopausal female, presents with iron deficiency anemia.

Perforation and Penetrations show as sudden severe pain, tender abdomen and shock. Perforation and penetrations are emergency situations.

Obstruction usually along the junction of stomach and small intestines. There is abdominal pain, nausea, vomiting, weight loss. Obstruction is also an emergency

MANAGEMENT
INVESTIGATIONS OF PEPTIC ULCER DISEASES:
A.) Since H. pylori infection is the primary cause of peptic ulcers, all patients with peptic ulcer should be assessed for the presence of H. pylori and eradicated with medications, when found.

One of 3 tests may be done
1.) Stool test for H. pylori antigens
2.) Urea Breath test
3.) Simple Blood test for(IgG) antibody formation, against H. pylori.

Ghana has a high prevalence of H pylori carriers, so this simple blood test, is very helpful, in finding and treating H. pylori associated peptic ulcers. (Provided, the one has never been treated for H. pylori, in the past.)

B.) Endoscopy of Stomach and upper bowels. Direct observation of the linings of stomach and upper bowel is the Gold standard. Endoscopy allows for biopsies and other test including testing directly for H pylori using the urea test could be done.

C.) Upper Gastrointestinal (X Ray and dye) series. For those who cannot get Upper endoscopy, this X Ray and barium dye series may be helpful.

D.) Computerized Tomographic Scan (C.T Scan) of Upper Abdomen. This test is reserved for the following conditions:

1.) Age >55 years with new onset upper belly pain
2.) Persons with abdominal pain and weight loss
3.) Gastrointestinal bleeding
4.) Recurrent vomiting
5.) Persons with iron deficiency anemia.
PREVENTION AND TREATMENT
Ulcers get better when antibiotics, are used to clear H pylori infections, when acid production is blocked and by not using, Aspirin, NSAIDs, Alcohol and tobacco.

A.) Persons with H. pylori stomach infections

Total eradication of the bacteria is the target.
Several antibiotic combination treatments are available.

The first line combo medications are taken for 2 weeks include:

a.) Clarithromycin/Amoxicillin/ proton pump inhibitors(PPI)

b.) Clarithromycin/Metronidazole/PPI
Second line: PPI/Levofloxacin/Amoxicillin, for 2 weeks

The urea breath test is used to confirm total eradication of H pylori.

The PPIs treatment could be continued indefinitely
B.) Proton Pump Inhibitors (PPI) They are used to block acid secretions in the stomach

The proton pump inhibitors (PPIs) include: Omeprazole, Lansoprazole, Esomeprazole.

The PPIs are taken daily and indefinitely for peptic ulcers associated with the following:

. Advanced age >65 years
. Male gender
. Blacks
. In the presence of diseases like: Obesity, Diabetes, Chronic bronchitis, Kidney disease, Heart diseases,

. Persons taking medications like: steroids, blood thinners.

C.) LIFEclass CHANGES
Tobacco Use: Stop smoking, continue PPIs indefinitely

Alcohol use: Reduce and eliminate alcohol
ASPIRIN & NSAIDs: When on these medications, co-treatment with PPIs help to reduce risk for ulcers.

SUMMARY:
Peptic ulcer diseases are very common and preventable.

Complications arising from untreated peptic ulcers are usually, life-threatening.

Eradication of H. pylori stomach infection and, indefinite use of anti-acid secreting agents, prevent peptic ulcers from recurring.

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