'Peptic ulcer' generally means an ulcer in the lower esophagus, stomach or duodenum. It may be acute or chronic. Fortunately, since the introduction of H. pylori eradication therapy, the prevalence of peptic ulcer is decreasing gradually in many communities.
What causes it:
Around 90% of duodenal ulcer patients and 70% of gastric ulcer patients are infected with H. pylori. Some gastric ulcers are due to chronic use of pain killers. Smoking is also a potential risk factor for gastric ulcer.
How ulcer is formed:
An ulcer usually develops if there is imbalance between aggressive factors and defensive factors.
Aggressive factor: digestive power of acid and pepsin.
Defensive factor: ability of gastric and duodenal mucosa to resist this digestive power.
When the aggressive factor takes the upper hand, ulcers develop and cause destruction of the gastrointestinal protective lining.
How it presents:
Peptic ulcer disease is a chronic condition that has a natural history of relapse and remission. The most common clinical presentation is that of recurrent upper abdominal pain which has some relation with food. Occasionally vomiting may also occur. Sometimes patient may only experience a vague sense of epigastric (upper abdomen) unease.
How to diagnose:
Endoscopy of upper gastrointestinal track is the investigation of choice for ulcer disorders. Ulcer should always be biopsied to rule out malignancy.
How to manage ulcer disease:
General measures: Cigarette smoking, aspirin and other pain killers should be avoided. If pain killer is needed, one should also take anti ulcer medications (omeprazole, esomeprazole, lansoprazole, ranitidine, cimetidine etc). Moderate alcohol is not harmful. Hot, spicy foods should be avoided as much as possible.
H. pylori eradication therapy:
This is the cornerstone of therapy for peptic ulcer. It prevents relapse and eliminates the need for long term therapy in most cases.
All patients who are H. pylori positive should be offered eradication therapy. It includes:
a. A proton pump inhibitor (omeprazole, esomeprazole etc -12 hourly)
b. Two antibiotics ( from amoxicillin 1gm, clarithromycin 500mg and metronidazole 400mg - 12 hourly)
Duration of treatment is seven to 14 days.
Some common side effects of H. pylori eradication therapy are:
b. Flushing and vomiting (when concomitant alcohol is taken)
c. Nausea, vomiting
f. abdominal cramp
Chronic non healing ulcers can be treated with partial gastrectomy. This is rarely done now a days due to highly effective pharmacological options.
Complications that may develop if ulcer is not treated properly:
b. Upper gastrointestinal bleeding
c. Obstruction of gastric outlet
Non ulcer dyspepsia
This is related to peptic ulcer disease. Here, patient experience pain and upper abdominal discomfort, fullness, satiety etc (just like peptic ulcer) . But when endoscopy is done no abnormality is detected. The cause of these vague symptoms is unknown. In fact, there is great overlap between non ulcer dyspepsia and irritable bowel syndrome. Patients are usually young. Women are affected twice as commonly as men. This disorder is also related to anxiety, alcohol misuse and intra abdominal malignancy (especially in old patient).