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| {{Infobox_Disease | | | {{Infobox_Disease | |
| Name = {{PAGENAME}} | | | Name = {{PAGENAME}} | |
| Image = Deep gastric ulcer.png | | | Image = Deep gastric ulcer.png | |
| Caption = Deep gastric ulcer | | | Caption = Deep gastric ulcer | |
| DiseasesDB = 9819 |
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| ICD10 = {{ICD10|K|25||k|20}}-{{ICD10|K|27||k|20}} |
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| ICD9 = {{ICD9|531}}-{{ICD9|534}} |
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| ICDO = |
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| OMIM = |
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| MedlinePlus = |
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| eMedicineSubj = |
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| eMedicineTopic = |
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| eMedicine_mult = |
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| MeshID = D010437 |
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| }} | | }} |
| {{Peptic ulcer}} | | {{Peptic ulcer}} |
| '''For patient information click [[{{PAGENAME}} (patient information)|here]]'''
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| {{CMG}} | | {{CMG}} ; {{AE}} {{MKK}} |
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| ==Overview==
| | {{SK}} Gastroduodenal ulcers; Peptic ulceration; gastric ulcer; duodenal ulcer. |
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| == Epidemiology == | | ==[[Peptic ulcer overview|Overview]]== |
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| ==History== | | ==[[Peptic ulcer historical perspective|Historical Perspective]]== |
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| ==Classification== | | ==[[Peptic ulcer classification|Classification]]== |
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| ==Stress and ulcers==
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| Despite the finding that a [[bacterial infection]] is the cause of ulcers in 80% of cases, [[bacterial infection]] does not appear to explain all ulcers and researchers continue to look at stress as a possible cause, or at least a complication in the development of ulcers.
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| An expert panel convened by the Academy of Behavioral Medicine research concluded that ulcers are not purely an [[infectious disease]] and that psychological factors do play a significant role.<ref name="medmag"/> Researchers are examining how stress might promote ''H. pylori'' infection. For example, ''Helicobacter pylori'' thrives in an acidic environment, and stress has been demonstrated to cause the production of excess stomach acid.
| | ==[[Peptic ulcer pathophysiology|Pathophysiology]]== |
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| The discovery that ''Helicobacter pylori'' is a cause of peptic ulcer has tempted many to conclude that psychological factors are unimportant. But this is dichotomised thinking. There is solid evidence that psychological stress triggers many ulcers and impairs response to treatment, while helicobacter is inadequate as a monocausal explanation as most infected people do not develop ulcers. Psychological stress probably functions most often as a cofactor with ''H pylori''. It may act by stimulating the production of [[gastric acid]] or by promoting behavior that causes a risk to health. Unravelling the aetiology of peptic ulcer will make an important contribution to the biopsychosocial model of disease.<ref name="bmj">{{cite web | url= http://bmj.bmjjournals.com/cgi/content/full/316/7130/538| title=Stress and peptic ulcer: life beyond helicobacter|accessdate=2007-08-26}}</ref>
| | ==[[Peptic ulcer causes|Causes]]== |
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| A study of peptic ulcer patients in a Thai hospital showed that chronic stress was strongly associated with an increased risk of peptic ulcer, and a combination of chronic stress and irregular mealtimes was a significant risk factor (PMID 12948263).
| | ==[[Peptic ulcer differential diagnosis|Differentiating Peptic ulcer from other Diseases]]== |
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| A study on mice showed that both long-term water-immersion-restraint stress and ''H. pylori'' infection were independently associated with the development of peptic ulcers (PMID 12465722).
| | ==[[Peptic ulcer epidemiology and demographics|Epidemiology and Demographics]]== |
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| == Pathophysiology == | | ==[[Peptic ulcer risk factors|Risk Factors]]== |
| [[Tobacco smoking]], [[Blood type|blood group]], spices and other factors that were suspected to cause ulcers until late in the 20th century, are actually of relatively minor importance in the development of peptic ulcers.<ref>For nearly 100 years, scientists and doctors thought that ulcers were caused by stress, spicy food, and alcohol. Treatment involved bed rest and a bland diet. Later, researchers added stomach acid to the list of causes and began treating ulcers with antacids. [http://digestive.niddk.nih.gov/ddiseases/pubs/hpylori/ National Digestive Diseases Information Clearinghouse]</ref> | |
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| A major causative factor (60% of gastric and 90% of duodenal ulcers) is chronic [[inflammation]] due to ''[[Helicobacter pylori]]'' that colonizes (''i.e.'' settles there after entering the body) the [[Pyloric antrum|antral]] [[mucosa]]. The immune system is unable to clear the infection, despite the appearance of antibodies. Thus, the [[bacterium]] can cause a chronic active [[gastritis]] (type B gastritis), resulting in a defect in the regulation of [[gastrin]] production by that part of the stomach, and gastrin secretion is increased. [[Gastrin]], in turn, stimulates the production of [[gastric acid]] by parietal cells. The acid erodes the [[mucosa]] and causes the ulcer.
| | ==[[Peptic ulcer screening|Screening]]== |
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| Another major cause is the use of [[NSAID]]s (see above). The gastric mucosa protects itself from [[gastric acid]] with a layer of mucus, the secretion of which is stimulated by certain prostaglandins. NSAIDs block the function of [[cyclooxygenase]] 1 (''cox-1''), which is essential for the production of these prostaglandins. Newer NSAIDs ([[celecoxib]], [[rofecoxib]]) only inhibit ''cox-2'', which is less essential in the gastric mucosa, and roughly halve the risk of NSAID-related gastric ulceration.
| | ==[[Peptic ulcer natural history|Natural History, Complications and Prognosis]]== |
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| [[Glucocorticoid]]s lead to atrophy of all [[epithelium|epithelial]] tissues. Their role in ulcerogenesis is relatively small. | | ==[[Peptic ulcer diagnosis|Diagnosis]]== |
| | | [[Peptic ulcer history and symptoms|History and Symptoms]] | [[Peptic ulcer physical examination|Physical Examination]] | [[Peptic ulcer Echocardiogram|Echocardiogram]] | [[Peptic ulcer laboratory tests|Laboratory Findings]] | [[Peptic ulcer x ray| X Ray]] | [[Peptic ulcer CT|CT]] | [[Peptic ulcer ultrasound|Ultrasound]] | [[Peptic ulcer other imaging findings|Other Imaging Findings]] | [[Peptic ulcer other diagnostic studies|Other Diagnostic Studies]] |
| There is debate as to whether ''Stress'' in the psychological sense can influence the development of peptic ulcers (see Stress and ulcers above). [[Burn (injury)|Burns]] and [[head trauma]], however, can lead to "stress ulcers", and it is reported in many patients who are on [[mechanical ventilation]].
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| [[Tobacco smoking|Smoking]] leads to [[atherosclerosis]] and vascular spasms, causing vascular insufficiency and promoting the development of ulcers through [[ischemia]].
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| Overuse of laxatives is also known to cause peptic ulcers.
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| A [[Family history (medicine)|family history]] is often present in duodenal ulcers, especially when [[ABO blood group system|blood group O]] is also present. Inheritance appears to be unimportant in gastric ulcers.
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| [[Gastrinoma]]s ([[Zollinger-Ellison syndrome]]), rare gastrin-secreting tumors, cause multiple and difficult to heal ulcers. | |
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| == Diagnosis ==
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| An [[esophagogastroduodenoscopy]] ([[EGD]]), a form of [[endoscopy]], also known as a [[gastroscopy]], is carried out on patients in whom a peptic ulcer is suspected. By direct visual identification, the location and severity of an ulcer can be described. Moreover, if no ulcer is present, EGD can often provide an alternative diagnosis.
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| The diagnosis of ''[[Helicobacter pylori]]'' can be by:
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| *Breath testing (does not require EGD);
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| *Direct culture from an EGD biopsy specimen;
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| *Direct detection of [[urease]] activity in a biopsy specimen;
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| *Measurement of [[antibody]] levels in [[blood]] (does not require EGD). It is still somewhat controversial whether a positive antibody without EGD is enough to warrant eradication therapy.
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| The possibility of other causes of ulcers, notably [[malignancy]] ([[gastric cancer]]) needs to be kept in mind. This is especially true in ulcers of the ''greater (large) curvature'' of the [[stomach]]; most are also a consequence of chronic ''H. pylori'' infection.
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| If a peptic ulcer perforates, air will leak from the inside of the gastrointestinal tract (which always contains some air) to the peritoneal cavity (which normally never contains air). This leads to "free gas" within the peritoneal cavity. If the patient stands erect, as when having a chest X-ray, the gas will float to a position underneath the diaphragm. Therefore, gas in the peritoneal cavity, shown on an erect chest X-ray or supine lateral abdominal X-ray, is an omen of perforated peptic ulcer disease.
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| ===Macroscopical appearance===
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| Gastric ulcers are most often localized on the lesser curvature of the stomach. The ulcer is a round to oval parietal defect ("hole"), 2 to 4 cm diameter, with a smooth base and perpendicular borders. These borders are not elevated or irregular as in the ulcerative form of gastric cancer. Surrounding mucosa may present radial folds, as a consequence of the parietal scarring.
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| ===Microscopical appearance===
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| A gastric peptic ulcer is a mucosal defect which penetrates the [[muscularis mucosae]] and muscularis propria, produced by acid-pepsin aggression. Ulcer margins are perpendicular and present chronic gastritis. During the active phase, the base of the ulcer shows 4 zones: inflammatory exudate, fibrinoid necrosis, granulation tissue and fibrous tissue. The fibrous base of the ulcer may contain vessels with thickened wall or with thrombosis.<ref name="pathologyatlas">{{cite web | url= http://www.pathologyatlas.ro/Peptic%20ulcer.html| title=ATLAS OF PATHOLOGY|accessdate=2007-08-26}}</ref>
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| == Differential Diagnosis ==
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| *Alcohol
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| *[[Alpha-1 Antitrypsin Deficiency]]
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| *Basophilic leukemia
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| *[[Burn]]s
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| *Cerebral [[trauma]]
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| *Chronic debilitated conditions
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| *[[Chronic obstructive pulmonary disease]]
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| *[[Chronic Renal Failure]]
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| *Cigarette smoking
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| *[[Cirrhosis]]
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| *[[Cystic Fibrosis]]
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| *Glucosteroids
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| *[[Helicobacter pylori infection]]
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| *[[Hyperparathyroidism]]
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| *Incompetant gastroesophageal sphincter
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| *[[NSAID]]s
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| *Severe systemic disease
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| *[[Zollinger-Ellison Syndrome]]
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| ==Treatment== | | ==Treatment== |
| | [[Peptic ulcer medical therapy|Medical Therapy]] | [[Peptic ulcer surgery|Surgery]] | [[Peptic ulcer primary prevention|Primary Prevention]] | [[Peptic ulcer secondary prevention|Secondary Prevention]] | [[Peptic ulcer cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Peptic ulcer future or investigational therapies|Future or Investigational Therapies]] |
| | ==Case Studies== |
| | [[Peptic ulcer case study one|Case #1]] |
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| Younger patients with ulcer-like symptoms are often treated with [[antacid]]s or [[H2 antagonist]]s before EGD is undertaken. [[Bismuth subsalicylate|Bismuth compounds]] may actually reduce or even clear organisms.
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| Patients who are taking [[NSAIDs|nonsteroidal anti-inflammatories]] (NSAIDs) may also be prescribed a [[prostaglandin]] [[analog (chemistry)|analogue]] ([[Misoprostol]]) in order to help prevent peptic ulcers, which may be a side-effect of the NSAIDs.
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| When ''H. pylori'' infection is present, the most effective treatments are combinations of 2 antibiotics (e.g. [[Erythromycin]], [[Ampicillin]], [[Amoxicillin]], [[Tetracycline]], [[Metronidazole]]) and 1 [[proton pump inhibitor]] (PPI). An effective combination would be [[Amoxicillin]] + [[Metronidazole]] + [[Pantoprazole]] (a PPI). In the absence of ''H. pylori'', long-term higher dose PPIs are often used.
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| Treatment of ''H. pylori'' usually leads to clearing of infection, relief of symptoms and eventual healing of ulcers. Recurrence of infection can occur and retreatment may be required, if necessary with other antibiotics. Since the widespread use of PPI's in the 1990s, surgical procedures (like "highly selective [[vagotomy]]") for uncomplicated peptic ulcers became obsolete.
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| Perforated peptic ulcer is a surgical emergency and requires surgical repair of the perforation. Most bleeding ulcers require endoscopy urgently to stop bleeding with cauterizations or injection.
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| ==Complications==
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| *'''[[Upper gastrointestinal bleeding|Gastrointestinal bleeding]]''' is the commonest complication. Sudden large bleeding can be life threatening<ref name="pmid9391242">{{cite journal |author=Cullen DJ, Hawkey GM, Greenwood DC, ''et al'' |title=Peptic ulcer bleeding in the elderly: relative roles of Helicobacter pylori and non-steroidal anti-inflammatory drugs |journal=Gut |volume=41 |issue=4 |pages=459–62 |year=1997 |pmid=9391242 |doi=}}</ref>. It occurs when the ulcer erodes one of the blood vessels.
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| *'''Perforation''' (a hole in the wall) often leads to catastrophic consequences. Erosion of the gastro-intestinal wall by the ulcer leads to spillage of stomach or intestinal content into abdominal cavity. Perforation at the anterior surface of stomach leads to acute [[peritonitis]], initially chemical and later bacterial peritonitis. Often first sign is sudden intense abdominal pain. Posterior wall perforation leads to [[pancreatitis]]; pain in this situation often radiates to back.
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| *'''Penetration''' is when the ulcer continues into adjacent organs such as liver and [[pancreas]]<ref>{{cite web |url=http://www.merck.com/mmhe/sec09/ch121/ch121c.html |title=Peptic Ulcer: Peptic Disorders: Merck Manual Home Edition |accessdate=2007-10-10 |format= |work=}}</ref>.
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| *Scarring and swelling due to ulcers causes narrowing in the duodenum and '''[[gastric outlet obstruction]]'''. Patient often presents with severe vomiting.
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| ==References==
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| {{reflist|2}}
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| == External links ==
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| *[http://www.pathologyatlas.ro/Peptic%20ulcer.html Pathology specimen of Gastric ulcer]
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| *[http://www.surgeons.org.uk/general-surgery/perforated-duodenal-ulceration.html A case report and tutorial on perforated duodenal ulcer]
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| *[http://www.peptic-ulcers.co.uk/causes.html Causes of Peptic ulcers]
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| {{SIB}}
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| {{Gastroenterology}} | | {{Gastroenterology}} |
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| [[Category:Gastroenterology]]
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| [[Category:Abdominal pain]]
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| [[bs:Ulcerozne lezije želuca]] | | [[bs:Ulcerozne lezije želuca]] |
| [[ca:Úlcera pèptica]] | | [[ca:Úlcera pèptica]] |
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