Up until the discovery of H. pylori in 1982, clinicians attributed peptic ulcers to lifestyle choices. This could have included consuming a diet rich in spicy foods and an inability to properly manage emotional and personal stress. A paper published in 1967 even reported that ulcers appeared in families with dominant and obsessional mothers; clinicians thought that these lifestyle factors resulted in an over production of gastric acid, leading to the formation of ulcers. Because of this, treatment for peptic ulcers at that time was limited to adopting a bland diet, bed rest, and taking medications that blocked new acid production and neutralized existing acid. Sadly, although these agents alleviated symptoms, the ulcers had a high rate of return until the recent discovery which has changed the tune of management hence success.
Peptic ulcer disease usually occurs in the stomach and proximal duodenum. The predominant causes in Uganda and worldwide is infection with helicobacter pylori and use of nonsteroidal antiinflammatory drugs (NSAIDs). Symptoms of peptic ulcer disease include epigastric discomfort especially, pain relieved by food intake or antacids and pain that occurs between meals, loss of appetite and weight loss. Older patients and patients with alarm symptoms indicating a complication or malignancy should have prompt endoscopy. Patients taking nonsteroidal anti – inflammatory drugs should discontinue their use. For younger patients with no alarm symptoms, a test – and – treat strategy based on the results of H. pylori infection is recommended. If H. pylori infection is diagnosed, the infection should be eradicated and antisecretory therapy given for four weeks.
Patients with persistent symptoms should be referred for endoscopy. Surgery is indicated if complications develop or if the ulcer is unresponsive to medications. Bleeding is the most common indication for surgery. Administration of antacids and endoscopic therapy control most bleeds. Perforation and gastric outlet obstruction are rare but serious complications. Peritonitis is a surgical emergency requiring patient rescustation.
Peptic ulcer disease is a problem of the gastrointestinal tract characterized by mucosal damage secondary to pepsin and gastric acid secretion. It usually occurs in the stomach and proximal duodenum; less commonly, it occurs in the lower esophagus, the distal duodenum, or the jejunum, as in unopposed hypersecretory state such as zollinger – Ellison syndrome , in hiatal hernias (Cameron ulcers) , or in ectopicmucosa taken in mecke’s diverticulum.
Peptic ulcer is one of the most common diseases of gastro intestinal tract, which, if not addressed, can increase in different communities. In Africa, the highest prevalence is reported to be in the great lakes region, were duodenal ulcer surgery forms the major part of all abdominal surgeries. The areas include Rwanda and Burundi, eastern DRC around Lake Kivu, extreme western Tanzania and south western Uganda. The epidemiology of both gastric and duodenal ulcers is characterized by marked geographic and temporal variations. The incidence, prevalence and mortality of gastric and duodenal ulcer vary four to tenfold among the developed countries, which is contrary to the developing world.
During the past 20 – 30 years, the numbers of patients who died from peptic ulcer disease, who has been operated upon, who saw physicians, or were hospitalized for peptic ulcer disease have decreased by more than 100 percent. These changes occurred within so short period that a genetic basis can be ruled out. Thus it seems likely that they stem from changes in environmental risk factors. The geographic variability of ulcer prevalence among populations of similar ethnicity and comparable medical standards still also hints at environmental influences.
The incidence and prevalence of PUD varies based upon on the presence of helicobacter pylori bacteria (H. pylori). Higher rates are found in developing countries Uganda inclusive, where H. pylori infection is higher. The incidence of PUD in H. pylori infected individuals is approximately 1 percent per year, a rate that is 6 to 10 fold higher than for uninfected individuals. Ulcer incidence increases with age for both duodenal ulcers and gastric ulcers but the incidence of uncomplicated PUD reached a plateau with age, where as for complicated PUD, the incidence increases with age. Duodenal ulcers occur two decades earlier than gastric ulcers particularly in males.
H. pylori infection and the use of nonsteroidal anti – inflammatory drugs (NSAIDs) are the predominant causes of peptic ulcer disease worldwide, accounting for 48 and 24 percent of cases, respectively. A variety of other infections and comorbidities are associated with a greater risk for peptic ulcer disease, like chronic kidney failure and tuberculosis. Critical illness, surgery or hypovolemia leading to splanchnic hypo perfusion may result in gastro duodenal erosions or ulcers (stress ulcers); these may be silent or manifest with bleeding or perforation. Smoking increases the risk of ulcer recurrence and slows healing.
Peptic ulcer is strongly associated with H. pylori infection. The prevalence of the infection in developed nations rise with age. In the developing world infection is more common, affecting up to 90 percent of adults. These infections are probably acquired in childhood by person to person contact. The vast majority of colonized people remain healthy and asymptomatic, and only a minority develops clinical disease. Around 90 percent of duodenal ulcer patients and 70 percent of gastric ulcer patients are infected with H. pylori. The remaining 30 percent of gastric ulcers are caused by NSAIDs like Aspirin, Ibuprofen, Naproxen, Diclofenac and Celecoxib), and this proportion is increasing in western countries as a result of H. pylori eradication strategies.
NSAIDs are the most common cause of peptic ulcer disease in patients without H. pylori infection. Typical effects of NSAIDs cause sub mucosal erosions. In addition, by inhibiting cyclooxygenase, NSAIDs inhibit the formation of prostaglandins which are chemicals with a protective effect on the layer of the stomach. Coexisting H. pylori infection increases the likelihood and intensity of NSAID induced damage. The annual risk of a life – threatening ulcer related complication is 1 to 4 percent in patients who use NSAIDs long – term with older patients at the highest risk. NSAIDs use is responsible for approximately one half of perforated ulcers, which occur most commonly in older patients who are taking aspirin or other NSAIDs for cardiovascular diseases or arthropathies.
Typical symptoms of peptic ulcer disease include episodic gnawing or burning epigastric pain; pain occurring two to five hours after meals or on an empty stomach; and nocturnal pain relieved by food intake, antacids or antisecretory agents. A history of pain after food intake, and night time awakening because of pain with relief following food intake are the most specific findings for peptic ulcer and help rule in the diagnosis. Less common features include indigestion, vomiting, loss of appetite, intolerance of fatty foods, heart burn, and a positive family history. The natural history and clinical presentation of peptic ulcer disease differ in individual populations. Abdominal pain is absent in at least 30 percent of older patients with peptic ulcer. Post prandial epigastric pain is more likely to be relieved by food or antacid in patients with duodenal ulcers than in those with gastric ulcers. Weight loss precipitated by fear of food intake is characteristic of gastric ulcers.
Anemia, hematemesis, black stool suggests bleeding from ulcers; vomiting suggests obstruction; anorexia or weight loss suggests cancer; persisting upper abdominal pain radiating to the back suggests penetration; and severe, spreading upper abdominal pain suggests perforation. Patients older than 55 years and those with alarm symptoms should be referred for prompt upper endoscopy. Patients younger than 55 years with no alarm symptoms should be tested for H. pylori infection through stool or urea breath test and advised to discontinue the use of NSAIDs, quit smoking, alcohol, and illicit drug usage and eradication therapy should be instituted. H. pylori infection should be eradicated with treatment for over four to eight weeks though eradication can be achieved with in 10 to 14 days; however shorter treatment courses are still under development. About 25 percent of patients with peptic ulcer disease have serious complications such as bleeding, perforation or gastric outlet obstruction. Silent ulcer complications are more common in older patients and in patients taking NSAIDs.
This content sponsored by Specialist Doctors International and written by DR. Matovu Richard
