Peptic ulcer

• Learning objective
• What is it ?
• What cause peptic ulcer?
• What are the symptoms of peptic ulcer?
• What is it diagnosed?
• How is it treated?
 Peptic ulcer

• Background
Peptic ulcer disease is the cause for dyspepsia
in about 10% of patients

95% of duodenal and 70% of gastric ulcers are

associated with Helicobacter pylori (H
Pylori)

Eradication of H pylori reduces the relapse rate

of ulcers
 Peptic ulcer
Background
Frequency
Ulcers of the small intestine are known as
duodenal ulcers

Duodenal ulcers affect about one in 10 people

at some point in their lives

Stomach ulcers are less common, and usually

affect people aged over 65
 Peptic ulcer
Background
Sex
The prevalence is probably equal in men and women

Age
Stomach and duodenal ulcers increases with age

This is probably related to the increased prevalence of

H pylori infection in older age groups
• Anatomy recall
• Stomach
• Is the most dilated portion of alimentary canal
• Situated between the end of esophagus and
the beginning of the small intestine
• It lies in the:
• epigastrium
• umbilical and
• left hypochondriac regions
• Anatomy recall
• Stomach
Capacity:
Birth: 30ml
Puberty: 800ml
Adult: 150ml
Anatomy recall
Stomach
Parts:
A cardiac
A body
A fundus

A pyloric part (antrum and canal)

Two covertures (greater and lesser)
Two surfaces (anterior and posterior)
 Anatomy recall
Stomach
Layers of Stomach Wall
Serosa
Muscularis
Submucosa
Mucosa
Stomach
Function
It is involves in the second phase of the
digestion

The stomach has three tasks

It stores swallowed food
It mixes the food with stomach acids
Then it sends the mixture on to the
small intestine
• Stomach cell types
• Three main cells:
1) Parietal cells (or oxyntic cells)
in fundus + body
Produced hydrochloric acid (HCl): a strong
acid that helps to break down food

2) Chief cells
in fundus + body
Produced pepsinogen: that on contact with
the acid of the gastric juice, convert to
proteolytic enzyme - pepsin
• Stomach cell types
3) G-cells
in antrum
Produce mucus
coats and lubricates the gastric surface, and
serves an important role in protecting the
epithelium from acid and other chemical
insults
• Anatomy recall
• Duodenum
The first part of the small intestine
It is shortest and Widest
Most fixed part of the small intestine
About 20-25cm long
It begin at the level pylorus and ends at the
junction Duodeno-jejunal flexure
• Anatomy recall
• Duodenum
It is divide into four parts
Superior Part (first part): 3 cm long, and most
movable of the four parts
Descending Part (second part); 8-10 cm long
Horizontal Part (third part): 10 cm long
Ascending Part (fourth part), 2-5 cm
 Peptic ulcer

• Anatomy recall
• Duodenum
• Duodenal wall has four layers:
Serosa
Muscularis
Submucosa
Mucosal
• Anatomy recall
• Duodenum
• Type cells
• S cells: secretin
• D cells: somatostatin
• Enterochromatin cells: GIP
• N cells: Neurotensin
 Peptic ulcer
Pathophysiology
A peptic ulcer occurs when an alteration occurs in the
aggressive and/or protective factors such that the
balance is in favor of gastric acid and pepsin
Any process
That increases gastric acidity (e.g. stress, fast)

That decreases prostaglandins production (e.g. Non

steroidal anti-inflammatory drugs: NSAIDS

Or interferes with the mucous layer (e.g.. H. pylori)

 Peptic Ulcer

• What is it?
• A peptic ulcer is a sore in the lining of the
stomach or duodenum, the first part of the
small intestine
 Peptic ulcer
Clinical
History

Patients may present with a wide variety of

symptoms, or they may remain completely
asymptomatic

Gastric and duodenal ulcers usually cannot be

differentiated based on history alone
 Peptic Ulcer
Clinical
History
Classic gastric ulcer pain is described as pain occurring shortly
after meals, for which antacids provide minimal relief

Duodenal ulcer pain often occurs hours after meals and at night

Pain is characteristically relieved with food or antacids

 Peptic Ulcer
Clinical
History
Pain can be sharp, dull, burning, or
penetrating

Many patients experience a feeling of

hunger

The pain may radiate into the back

 Peptic ulcer
Clinical
History

The pain from gastric/duodenal ulcers is

typically located in the epigastrium;
however, it can also be perceived in the right
upper quadrant and elsewhere

Pain with radiation to the back is

suggestive of a posterior penetrating
gastric ulcer complicated by pancreatitis
 Peptic ulcer
Clinical
History
Patients with bleeding gastric/duodenal ulcers
may give a history of hematemesis, melena
(coffee-ground), or episodes of
presyncope

Melena can be intermittent over several days

or multiple episodes in a single day

Rarely, a briskly bleeding ulcer can present as

gross hematochezia
 Peptic ulcer
Clinical
History

About 20-40% of patients describe bloating,

belching, or symptoms suggestive of
gastroesophageal reflux (GER)
 Peptic ulcer
Physical
Physical examination usually is not helpful

Right upper quadrant tenderness may suggest a

biliary etiology or, less frequently, peptic ulcer
disease

In the presence of gastric outlet obstruction

* abdominal distension and
* succussion splash may be found
 Peptic ulcer
• Physical
A palpable mass should raise the suggestion of a
gastric malignancy

Involuntary guarding is indicative of peritonitis

secondary to gastric perforation

Patients should be checked for melena, which is

indicative of bleeding from a gastroduodenal ulcer

Digital rectal examination (DRE) can be easily

performed in the office to check for melena
 Peptic ulcer disease
• Causes
1) H pylori infection
H pylori infection and NSAIDs use account for most
cases of PUD

2) Nonsteroidal anti-inflammatory drugs

Similar to H pylori infection, NSAID use is a common cause for
PUD
 Peptic ulcer disease

• Causes
• 3) Severe physiologic stress
Burns
CNS trauma
Surgery
Severe medical illness
 Peptic ulcer disease
• Causes
• 3) Hypersecretory states (uncommon)
* Gastrinoma (Zollinger-Ellison syndrome) or multiple endocrine
neoplasia (MEN-I)
* Antral G cell hyperplasia
* Systemic mastocytosis
* Basophilic leukemias
 Peptic ulcer disease
• Causes
• 4) Diseases associated with an increased risk of PUD
include:
* cirrhosis
* chronic obstructive pulmonary disease
* renal failure and
* organ transplantation
 Peptic ulcer disease

• Causes
5) Lifestyle factors
Smoking
Alcohol use
Caffeine intake
Genetics (family history)
 Peptic ulcer disease
• Differential Diagnoses
Biliary Colic
Myocardial Ischemia
Appendicitis (PUD perforation)
Cholecystitis
Pancreatic Cancer
Cholelithiasis
Pancreatitis, Acute
Gastritis, Acute
Pancreatitis, Chronic
Gastritis, Chronic
Gastroesophageal Reflux Disease
Mesenteric Artery Ischemia
 Peptic ulcer disease
Workup
Laboratory Studies
* In most patients with uncomplicated PUD, routine laboratory
tests usually are not helpful

* Documentation of PUD depends on radiographic and

endoscopic confirmation

* If the diagnosis of PUD is unclear or complicated and PUD is

suspected, obtaining CBC, liver function tests (LFTs),
amylase, and lipase might be useful
 Peptic ulcer disease

• Imaging Studies
• Upper gastrointestinal series
Double-contrast radiography performed by an
experienced radiologist might approach the
diagnostic accuracy of upper GI endoscopy.
However, it has been replaced largely by diagnostic
endoscopy, when available
 Peptic ulcer disease
• Imaging Studies
Upper gastrointestinal series

It is not as sensitive as endoscopy for establishing a

diagnosis of small ulcers (<0.5 cm)

It also does not allow for obtaining a biopsy to rule

out malignancy in the setting of a gastric ulcer or
to assess for H pylori infection in the setting of a
gastroduodenal ulcer
 Peptic ulcer disease

• Treatment
Medication
Surgery (complications)
 Peptic ulcer disease
• Treatment
Medication
PPI-based triple therapies for H pylori are
considered the first-line therapies for the
treatment of H pylori in the United States with a
cure rate of 85-90%

These regimens consist of:

1) a PPI
2) amoxicillin and 3) clarithromycin
for 7-14 days
 Peptic ulcer disease

Treatment
Medication
PPI-based triple therapies consist of a 14-day
treatment of the following:
Omeprazole (Prilosec): 20 mg PO bid or
Lansoprazole (Prevacid): 30 mg PO bid or
Rabeprazole (Aciphex): 20 mg PO bid or
Esomeprazole (Nexium): 40 mg PO qd
 Peptic ulcer disease
Treatment
Medication
Quadruple therapies for H pylori infection
are generally reserved for patients who have
failed a course of treatment and are
administered for 14 days
The treatment includes the following drugs
* PPI: PO bid and
* Bismuth: 525 mg PO qid and
* Metronidazole : 500 mg PO qid and
* Tetracycline: 500 mg PO qid
 Peptic ulcer disease
Treatment
Surgery (complications)
* Abdominal pain * Chest pain
* Bleeding
* Anemia
* Gastrointestinal perforation (rupture)
* Pyloric stenosis
* Hypovolemic shock
* Penetration ( acute pancreatitis)
* Cancerization ?
THANKS