Peptic ulcer disease
Peptic ulcer is a lesion in the mucosa of the stomach or duodenum in which acid and pepsin play a major role, the term is often used to encompass any gastric or duodenal ulceration. This includes ulceration that may occur from drugs (NSAIDs) or excessive gastrin production (Zollinger-Ellison syndrome).
Peptic ulcer disease is common. It usually presents after the age of 15 and is equally common in both sexes.
Causes of Peptic Ulcer:
Although the term peptic ulceration suggests that the main causative factor is increased acid secretion, patients with peptic ulcer disease usually have normal acid secretion rates.
The currently most widely accepted causative agent is H. pylori. Approximately 95% of duodenal ulcers and 70% of gastric ulcers are associated with H. pylori (but only 15% of H. pylori colonized individuals will develop peptic ulcer disease). The odds of developing peptic ulceration are increased 2-fold in H. pylori positive patients. Peptic ulceration is also more common in patients on NSAIDs (Non Steroidal Anti Inflammatory Drugs) (36%) as compared to patients who are not on NSAIDs (8%) in clinical studies. Weaker associations of peptic ulcer disease include smoking, alcohol, family history and blood group O.
Rare causes of peptic ulceration include hyperparathyroidism and Zollinger-Ellison syndrome, which results from a gastrinoma that usually arises from the G-cells in the pancreas, resulting in excess gastrin production and increased gastric acid secretion.
Symptoms of Peptic ulcer
Dyspepsia (recurrent upper abdominal pain) is the most common symptom. The pain may be related to meals and may occur at night. Associated symptoms include nausea and vomiting. Although attempts have been made to differentiate gastric from duodenal ulceration from the history, this has proved to be inaccurate and does not influence subsequent management.
Warning symptoms of significant disease or potential complications are dysphagia, weight loss and haematemesis. Patients with these symptoms or those who are over 35 years at initial presentation require urgent upper gastrointestinal endoscopy to screen for complications or malignancy (oesophageal, gastric).
Complication of peptic ulcer:
Complications of peptic ulcer disease include dyspepsia, upper gastrointestinal haemorrhage and gastric or duodena perforation. Chronic or recurrent ulceration may result in peptic strictures of the oesophagus or gastric outflow obstruction (pyloric stenosis).
Diagnosis of Peptic Ulcer
Screening for H. pylori
No investigations apart from screening for H. pylori colonization are required for young patients without any warning symptoms, as empirical treatment can commence on clinical diagnosis.
Further investigations
Upper gastrointestinal endoscopy
Upper gastrointestinal endoscopy is required for patients with warning symptoms and those over 35 years to screen for complications or oesophageal or gastric cancer.
Treatment of Peptic ulcer
Risk factor modification
Ideally patients should stop taking NSAIDs, but often this may not be possible; alternatives include the concomitant long-term use of a proton pump inhibitor. General advice involves stopping smoking and reducing alcohol intake, but there is little evidence to support the efficacy of these recommendations.
Medical management
H. pylori eradication
Triple therapy is recommended for all patients who are H. pylori positive. In patients with duodenal ulcers, eradication therapy was associated with a lower relative risk of persistent ulcer compared to acid suppression alone, but no differences were found for patients with gastric ulcers , nor does eradication therapy prevent recurrences in patients with duodenal ulcers.
Initial triple therapy
First-line triple therapy for H. pylori eradication consists of a proton pump inhibitor with either clarithromycin and amoxicillin or clarithromycin and metronidazole. Although many combinations and treatment durations have been proposed, the most effective are the twice-daily dosing, 1-week duration regimens such as omeprazole 20 mg twice daily, amoxicillin 1 g twice daily and clarithromycin 500 mg twice daily.
Initial eradication regimens progressively change due to failure rates associated with the development of antibiotic-resistant strains of H. pylori. Currently metronidazole-resistant strains are common and clarithromycin resistance is increasing. Dual therapy often fails to eradicate H. pylori and promotes emergence of resistant organisms.
Rescue therapy
Rescue therapy for failed initial eradication should consist of a different combination of antibiotics to that used for initial treatment, administered for 10-14 days. Selection of further antibiotic treatment should be based on antimicrobial susceptibilities from primary or secondary endoscopy biopsy culture results.
Proton pump inhibitors
A proton pump inhibitor is currently the standard treatment, and part of triple therapy. Thereafter, symptomatic patients, those with complicated peptic ulcer disease (presenting with bleeding, stricture or perforation) and those patients who require NSAIDs may still require long-term proton pump inhibitor therapy. Intermittent on-demand therapy is suitable for patients without complications for the control of symptoms.
Surgical management
Peptic ulcer surgery
Peptic ulcer surgery is now extremely rare for failed medical therapy due to the powerful acid suppression by proton pump inhibitors. Currently surgery is usually reserved for the development of complications such as perforation, severe bleeding and rarely stricture formation.
In patients with gastric or duodenal perforation, a primary repair is usually performed on laparotomy. A pyloroplasty to increase the diameter of the gastric outlet may be performed for patients with pyloric stenosis due to peptic stricture. A longitudinal incision is performed through the pylorus and closed as a transverse defect. Alternatively, a gastroenterostomy may be performed to bypass the narrowed pylorus. Gastrectomy is rarely performed unless there is evidence of malignancy.
Prognosis of Peptic ulcer
Peptic ulcer disease is a chronic relapsing condition. Symptom control with proton pump inhibitor therapy is usually achieved in the vast majority. Up to 15% may suffer with upper gastrointestinal haemorrhage requiring hospital admission, and less than 5% will require surgical intervention
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