peptic ulcer at aglance
Can occur:o In esophagus.
o In jejunum in Zollinger-Ellison syndrome (↑ Gastrin à HCl).
o After gastroenterostomy.
o In Meckel’s diverticulum (contains ectopic gastric mucosa).
Epidemiology
· Duodenal ulcer (DU) > Gastric ulcer (GU).
· DU in ♂ > ♀.
· Incidence: ↑ with age.
Etiology
1. H. pylori.
2. Genetic susceptibility.
3. NSAIDs (mainly for Gastric ulcer).
4. Hyperthyroidism (Ca+2 à acid secretion).
5. Zollinger-Ellison syndrome (hyperacidity state).
Pathology
· Gastric ulcer may occur in any part of stomach, but is most commonly in lesser curve.
· Most duodenal ulcers occur in duodenal cap.
Clinical Features
Symptoms:
1. Epigastric pain: characteristic, pt points directly to epigastrium.
2. Indigestion.
3. Nausea, heartburn (due to acid regurgitation).
4. Anorexia & weight loss (esp. in gastric ulcer).
N.B. Patients can present for the 1st time with major complications: e.g. hematemesis / malena / perforation.
N.B. In gastric ulcer, pain is aggravated by food.
Signs:
Epigastric tenderness: But it does not necessarily imply disease & is usually found in non-ulcer dyspepsia.
N.B. Physical exam is of little help in establishing diagnosis of uncomplicated peptic ulcer diseases.
Investigations
1. Endoscopy: 1st Investigation with biopsy of all gastric ulcers.
2. Barium meal (double-contrast technique).
Treatment
1. Eradication of H. pylori.
2. Omeprazole.
3. H2 receptor antagonists.
4. Stop smoking & NSAIDs.
5. Surgery.
Surgical Mx
· Currently surgery is reserved for complications. In the past, 2 types of operation were performed:
1. Partial gastrectomy: to remove antral area that secretes gastrin.
a. Billroth I partial gastrectomy à best for GU
b. Billroth II (Polya gastrectomy) à GU / DU.
2. Vagotomy:
a. Truncal vagotomy + gastroenterostomy / pyloroplasty.
b. Selective vagotomy + gastroenterostomy / pyloroplasty.
c. Highly selective vagotomy
o Proximal gastric vagotomy.
o Nerves supplying parietal cells are transected.
Long-term Complications of surgery
1. Recurrence of ulcer with same symptoms.
2. Dumping:
o Nausea, distension associated with sweating, faintness, palpitations.
o Occurs in patients following gastrectomy / gastroenterostomy.
o Due to dumping of food into jejunum à rapid fluid dilution of the high osmotic load.
o Not a clinical problem.
3. Diarrhea: seen after vagotomy.
4. Vomiting (Afferent loop syndrome / bilious vomiting).
§ Because food gets trapped owing to altered anatomy.
5. Nutritional complications: Most commonly Fe+ def anemia caused by poor absorption.
Complications
H. pylori eradication is imperative.
1. Hemorrhage.
2. Penetration.
3. Perforation.
· More in duodenal ulcers (usually in peritoneal cavity).
· May occur in lesser sac.
· Diagnosis: air under diaphragm.
4. Fibrosis:
a. Hourglass stomach.
b. Teapot stomach.
c. Pyloric stenosis / obstruction:
· Gastric outflow obstruction.
· Occur in prepyloric / duodenum.
· Occurs because:
1. Of active ulcer with surrounding edema.
2. Healing has been followed by scaring.
3. Gastric malignancy.
4. External compression from a pancreatic cancer.
· Main symptom: projectile vomiting (no bile).
· On physical examination: abdomen has succussion splash.
· Diagnosis: Barium meal (soap-plate appearance).
· Most patients require surgery.
