Peptic Ulcer - Causes, Diagnosis and Treatment

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

Irritable bowel syndrome (IBS) – Symptoms, Diagnosis and Treatment

IBS is the commonest Functional Gastro Intestinal Disorder. Female sufferers outnumber male counterpart. Reasons for this include the fact that anxiety and depression scores are higher in women than in men and the gut may be more sensitive to various stimuli in women. It is likely that men and women perceive internal events in the abdomen differently and that women may be more focused on these events. Food and eating are of more special psychological significance for women, as evidenced by a much higher incidence of eating disorders in women. The whole pelvic region carries a more specific significance for women, being associated not only with defecation, urination and sexuality but additionally with menstruation, pregnancy and childbirth.

IBS - a multisystem disorder

IBS patients suffer from a number of non-intestinal symptoms as stated below. The non-intestinal symptoms of IBS can be more intrusive than the classical features of IBS. IBS coexists with chronic fatigue syndrome, fibromyalgia and temporomandibular (Jaw joint) joint dysfunction


Gynaecological symptoms
Painful periods (dysmenorrhoea)
Pain following sexual intercourse (dyspareunia)
Premenstrual tension

Urinary symptoms
Frequency
Urgency
Passing urine at night (nocturia)
Incomplete emptying of bladder

Other symptoms
Back pain
Headaches
Bad breath, unpleasant taste in the mouth
Poor sleeping
Fatigue

Infectious diarrhoea precedes the onset of IBS symptoms in 7-30% of patients. Whether this is a factor for all patients or just a small subgroup remains controversial. Risk factors in these patients have been shown to include female gender, severity and duration of diarrhoea, pre-existing life events and high hypochondriacal anxiety and neurotic scores at the time of the initial illness.

Symptoms of anxiety and depression are more common in IBS patients and stress or life events often precedes the onset of chronic bowel symptoms.

Factors which are known to trigger IBS


Gastrointestinal infection
Antibiotic therapy
Pelvic surgery
Psychological stress
Psychological trauma
Sexual, physical, verbal abuse
Mood disturbances
Anxiety, depression
Eating disorders
Food intolerance


Diagnostic criteria (Rome II 1999)

These criteria state that, in the preceding 12 months there should be at least 12 weeks (consecutive) of abdominal discomfort or pain that has two of three of the following features:

Relieved with defecation; and/or onset associated with a change in frequency of stool; and/ or onset associated with a change in form(appearance) of stool.

The following symptoms cumulatively support the diagnosis of IBS:

#abnormal stool frequency ('abnormal' may be defined as > 3/day and <>
#abnormal stool form (lumpy/hard or loose/watery stool)
#abnormal stool passage (straining, urgency, or feeling of incomplete evacuation)
#passage of mucus
#bloating or feeling of abdominal distension.

These symptoms can be used to sub classify patients into diarrhoea- and constipation-predominant forms of IBS. In practice a third subgroup of alternating IBS exists, in which constipation and diarrhoea alternate. The three forms have equal frequency. Many patients with constipation have abdominal discomfort or pain with bloating or distension so there is considerable overlap with constipation-predominant IBS. The decision as to whether to investigate and if so what choice of investigations is required should be based on clinical judgement. Pointers to the need for thorough investigation are the presence of the above symptoms in association with rectal bleeding, nocturnal pain, fever and weight loss. Treatment Current strategies for treatment of IBS are based on the biopsychosocial conceptualization of IBS with targeting of central and end-organ therapies. End organ and central approaches to treatment should not be mutually exclusive and can be used in sequence and in combinations. Hydroxytryptamine (HT3)-receptor antagonists for diarrhea predominant IBS, HT4-receptor agonists for constipation predominant IBS as well as kappa opioid agonists for use in patients in whom visceral hyperalgesia plays a predominant role in the pathogenesis of their symptoms may become available.

These are the plan of management of IBS

Explore dietary triggers - Refer to dietician

High-fibre diet ± fibre supplements for constipation - Refer to dietician ± prescribe ispaghula husk

Anti-diarrhoeal drugs for bowel frequency – Loperamide, Codeine phosphate, Co-phenotrope

Smooth muscle relaxants for pain - Mebeverine hydrochloride, Dicycloverine hydrochloride, Peppermint oil


Central treatment consists of - Physiological explanation of symptoms, Psychotherapy, Hypnotherapy, Cognitive behavioural therapy and Antidepressant drug therapy

Premenstrual Syndrome (PMS)

What is Premenstrual syndrome? or, PMS?

A very common condition affecting the women mostly in their 30s and 40s. They notice premenstrual worsening of their physical wellbeing and mood. The symptom may vary month to month; being minimal in one month severe in other and moderate discomfort in some months. Some women also notice that the symptoms are less when they are on combined contraceptive pills. 3% of the affected women get these symptoms regularly and they may be so severe, that it cause major disruption to their lives. This syndrome is also known as Premenstrual tension or. PMT

What are the symptoms of PMS or PMT?

Tension, irritability, depression, bloating sensation, heaviness and tenderness in the breasts, headache, craving for carbohydrates, lack of sexual drive or, libido are the common symptoms. Many other bizarre symptoms may appear. To know whether one has PMS or, not it is essential to keep a diary of events. This diary will help the treating doctor to differentiate PMS with other disorders and will be helpful to find any psychological disturbance, she may be having. If she is having her symptoms worst premenstrual, she will have at least one week symptom free period after her menstruation.

How to treat Premenstrual syndrome (PMS)?

Reassurance is very important and she must understand this is not going to produce any serious disease or, cancer in future. Cooperation from the spouse and children is required to cope up with life. Find self help group support in the area. Improvement of diet, proper exercising, Yoga and rest, avoiding tobacco and alcohol will help. Herbal remedies though not tested properly some find them helpful. Try sage and fennel for irritability. Pyridoxine (Vitamin B6) 10 mg orally daily, either continuously or during the discomfort may help to elevate the mood and relive headache.

For severe cyclical pain in the breasts, cyclical mastalgia:

Avoid eating saturated fats as they increases the affinity of the oestrogen receptors for oestrogen.

Gamolenic Acid 160 mg orally 12 hourly

Bromcryptine 2.5 mg orally twice daily from 10^th to 26^th day of the cycle ( prescribed even when the prolactin level is within normal limit)

Danazol 100 – 200 mg 12 hourly orally for 7 days prior to menstruation.

Suppression of ovulation help in relieving symptoms in PMS

Yasmin a new entrant in combination pill is specially helpful to alleviate symptoms of PMS by suppressing ovulation.

Oestrogen Implants with cyclical progesterone is also used.

Danazol can also be given to suppress ovulation, but has other side effects like pimple, hair fall, weight gain etc.

Diuretics Spironolactone 25mg orally 6 hourly is also prescribed from 16^th to 26^th day of the cycle ( 1^st day being the first day of menstruation) when there is excessive fluid retention.

Other than these alprazolam, mefenamic acid and other analgesics are used to treat PMS.

In intractable patients removal of uterus and ovaries may be done and results are 96% satisfactory. These women should receive oestrogen replacement (HRT) following their operation.

This article is also republished at India Study Channel

Secondary Dysmenorrhoea

Cyclical Pain Abdomen Related With Menstruation – Dysmenorrhoea

The commonest complain in my Out Patient Department I encounter from all age group of patients is cyclical pain associated with menstruation. The medical term for this condition is dysmenorrhoea. The condition is very common and most of the time, not always, it is nothing serious. In this article you will have some idea how and why such cyclical pain occurs and what one should do?

More than 90% of women some time or other, in their life experience pain during her menstruation. In clinical terms we have two types of dysmenorrhoea.

1. Primary dysmenorrhoea
   
2. Secondary dysmenorrhoea
   

Secondary dysmenorrhoea:

This kind of cyclical pain during menstruation is associated with some disease/ pathology in the genital organ i.e., uterus, fallopian tubes and ovaries. Secondary dysmenorrhoea develop years after the onset of menstruation. Here the pain begins 1 – 2 weeks prior to menstrual flow and persists till few days after cessation. The mechanism of secondary dysmenorrhoea is not fully understood and NSAID ( Nonsteroidal Antinflammatory Drugs) do not provide full relief. Treatment to this kind of dysmenorrhoea should be directed to the treatment of the underlying cause.

Here are the few common gynaecological cause of secondary dysmenorrhoea:

1. Adenomyosis
   
2. Endometriosis
   
3. Fibroid uterus
   
4. Pelvic congestion syndrome
   
5. Sub acute pelvic infection
   
6. Adhesions
   

Adenomyosis:

Though this is a disease of women in their forties, but frequently encountered in younger women nowadays. The normal site for endometrium is lining of the uterine cavity. In this disease endometrium is abnormally found in the musculature of the uterus. This make the uterus large and painful during menstruation. The affected woman complains painful heavy periods and pain during intercourse.

Diagnosis of adenomyosis is easily done from the symptoms, clinical findings and ultrasonography.

There is no medical treatment available at present for this condition. The affected organ uterus has to be removed by operation (Hysterectomy) after she completes her family. Till such time symptomatic treatment with analgesics are done.

Endometriosis:

Nowadays an extremely common condition affecting girls and women of almost all age group after 16 years! I will post a separate article on this condition to give a little in depth information. In this condition endometrium is found in different abnormal location inside the abdominal cavity and even the skin. In each cycle endometrium in these abnormal sites bleed along with the normal endometrium, lining the uterine cavity. This bleeding causes severe pain and varied kind of symptoms depending on the site of bleeding. Endometriosis is a major cause of infertility. Painful, sometimes incapacitating heavy menstruation, pain during intercourse are the major complains.

Diagnosis of endometriosis is done by clinical history, examination, ultrasonography and finally by diagnostic laparoscopy.

Definitive treatment of endometriosis is removal of ovaries and uterus. Unfortunately the disease is mostly found in young woman without any child. Different kind of hormonal treatment and conservative surgery are usually advised to them. Once they complete their family and still the symptoms persist removal of uterus and ovaries (hysterectomy) done.

Fibroid Uterus:

These are benign tumors in the uterine musculature. Though mostly remain symptomless, but sometimes obstructs the natural flow of menstruation and causes pain. The other symptoms are swelling of abdomen, excessive bleeding during and sometimes in between menstruation, repeated abortions, failure to conceive depending on the size and site of the tumor.

Diagnosis of fibroid uterus is done from complain of the patients, clinical examination and ultimately by ultrasonography.

Treatment of fibroid uterus: This depend on the symptoms, age and whether the woman has completed her family or not. If family is completed, in a symptomatic patient, the affected organ is removed surgically ( Hysterectomy). Otherwise removal of the tumors (conservative surgery) is done.

Pelvic congestion syndrome:

Common sufferers are the women in their reproductive age. This condition is most likely associated with emotional stress, which in turn increases the blood flow to the genital organs i.e. uterus, fallopian tubes and ovaries. This causes pain during menstruation, heavy bleeding and pain while intercourse ( dysparunea).

Diagnosis of pelvic congestion syndrome is done from history, clinical examination, ultrasonography, MRI, trans uterine pelvic venogram and laparoscopy.

Treatment depends on the age and the number of children the woman has. If her family is not completed conservative treatment with analgesics and different hormones are done. Once she completes her family and still suffers hysterectomy is done.

Subacute pelvic infections:

Inadequately treated infection of the uterus and its appendages, fallopian tubes and ovaries may persist and causes dysmenorrhoea, excessive bleeding and dysparunea. Proper treatment of the infection may solve the issue but in resistant cases hysterectomy is the answer.

Adhesions:

Adhesions may occur with the surrounding organs like urinary bladder, intestines, rectum and within the uterus and its organs i.e. ovaries and fallopian tubes. The cause of such adhesions may be repeated infections, sexually transmitted diseases or any abdominal or vaginal operations like MTP (Medical Termination Of Pregnancy).

The woman presents with dysmenorrhoea, dysparunea, difficulty in passing urine and stool. Diagnosis is done by laparoscopy . The minor adhesions are usually dealt with freeing the uterus and appendages by operation either by laparoscopy or open operation. In bad type of such adhesion removal of uterus is the only answer.

Cyclical Pain Abdomen Related With Menstruation – Dysmenorrhoea

The commonest complain in my Out Patient Department I encounter from all age group of patients is cyclical pain associated with menstruation. The medical term for this condition is dysmenorrhoea. The condition is very common and most of the time, not always, it is nothing serious. In this article you will have some idea how and why such cyclical pain occurs and what one should do?

More than 90% of women some time or other, in their life experience pain during her menstruation. In clinical terms we have two types of dysmenorrhoea.

a) Primary dysmenorrhoea
b) Secondary dysmenorrhoea

Primary dysmenorrhoea : It is a condition where the girl/ woman having cyclical pain at menstruation, and on investigation no disease is found in the genital organs. This is the commonest form of dysmenorrhoea see in young adults. These usually appears within one to two years after girls starts menstruating and usually lasts for few years and in most cases subside after having a baby. Sometimes it may also continue up to 40 years of age.

Typically the pain starts few hours before or, at the onset of menstruation and last for 48 to 72 hours. The main is similar to labor pain to some extent. The affected girl have cramps in lower abdomen along with backache . Most girls can tolerate this very easily and none of their daily activities are hampered due to this. In few others, it is severe enough to detain her from normal activities and may be associated with nausea, vomiting, dizziness, headache and even fainting attack in severe cases.

Pain sensitivity varies with the individuals. Some can tolerate pain better than others. This may be one of the causes for such condition in some girls. The intensity of the process of pain may also be greater in few of them. Whatever may be the reason, be assured that this is not any dangerous condition and in no way it is going to affect her future sex life or child bearing.

Why pain during menstruation happens?

Prostaglandin, a chemical is produced while a girl is menstruating is the culprit for these symptoms. It produces contractions in the uterine muscles and affect the other organs to produce different kind of symptoms. Girls who are having increased sensitivity to prostaglandins get more symptoms.

What to do when I am in pain during my period (menstruation)?

If this problem is bearable and not detaining you from any activity of yours, don’t worry at all. Have nutritious food and do regular exercises and enjoy your life. In case, you are incapacitated for few days each month, you should visit a gynaecologist. He will probably order a ultrasonography to exclude any other problem in your genital organ. If nothing found abnormal, which is true for most cases, nothing to worry about.

Treatment of Primary dysmenorrhoea:

Analgesics work by inhibiting the prostaglandins, the culprit chemical causing this. Any nonsteroidal anti-inflammatory drug (NSAID) for 2 – 3 days (deliberately I am not writing the name – get it prescribed by your doctor) will relieve the symptoms. The common mistake done by many general practitioners, medicine shops, and the patient is they prescribe or take antispasmodics like Buscopan. This will not help alone. You have to take NSAID along with it.

Know about Secondary dysmenorrhoea here.