Peptic ulcer: Difference between revisions
| Line 30: | Line 30: | ||
== Diagnosis == | == Diagnosis == | ||
The diagnosis of ''[[Helicobacter pylori]]'' can be by: | The diagnosis of ''[[Helicobacter pylori]]'' can be by: | ||
*Breath testing (does not require EGD); | *Breath testing (does not require EGD); | ||
Revision as of 19:59, 3 February 2012
| Peptic ulcer | |
 | |
|---|---|
| Deep gastric ulcer | |
| ICD-10 | K25-K27 |
| ICD-9 | 531-534 |
| DiseasesDB | 9819 |
| MeSH | D010437 |
|
Peptic ulcer Microchapters |
|
Diagnosis |
|---|
|
Treatment |
|
Surgery |
|
Case Studies |
|
2017 ACG Guidelines for Peptic Ulcer Disease |
|
Guidelines for the Indications to Test for, and to Treat, H. pylori Infection |
|
Guidlines for factors that predict the successful eradication when treating H. pylori infection |
|
Guidelines to document H. pylori antimicrobial resistance in the North America |
|
Guidelines for evaluation and testing of H. pylori antibiotic resistance |
|
Guidelines for when to test for treatment success after H. pylori eradication therapy |
|
Guidelines for penicillin allergy in patients with H. pylori infection |
|
Peptic ulcer On the Web |
|
American Roentgen Ray Society Images of Peptic ulcer |
For patient information click here
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Epidemiology
History
Classification
Pathophysiology
Diagnosis
The diagnosis of Helicobacter pylori can be by:
- Breath testing (does not require EGD);
- Direct culture from an EGD biopsy specimen;
- Direct detection of urease activity in a biopsy specimen;
- 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.
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.
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.
Macroscopical appearance
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.
Microscopical appearance
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.[1]
Differential Diagnosis
- Alcohol
- Alpha-1 Antitrypsin Deficiency
- Basophilic leukemia
- Burns
- Cerebral trauma
- Chronic debilitated conditions
- Chronic obstructive pulmonary disease
- Chronic Renal Failure
- Cigarette smoking
- Cirrhosis
- Cystic Fibrosis
- Glucosteroids
- Helicobacter pylori infection
- Hyperparathyroidism
- Incompetant gastroesophageal sphincter
- NSAIDs
- Severe systemic disease
- Zollinger-Ellison Syndrome
Treatment
Younger patients with ulcer-like symptoms are often treated with antacids or H2 antagonists before EGD is undertaken. Bismuth compounds may actually reduce or even clear organisms.
Patients who are taking nonsteroidal anti-inflammatories (NSAIDs) may also be prescribed a prostaglandin analogue (Misoprostol) in order to help prevent peptic ulcers, which may be a side-effect of the NSAIDs.
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.
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.
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.
Complications
- Gastrointestinal bleeding is the commonest complication. Sudden large bleeding can be life threatening[2]. It occurs when the ulcer erodes one of the blood vessels.
- 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.
- Penetration is when the ulcer continues into adjacent organs such as liver and pancreas[3].
- Scarring and swelling due to ulcers causes narrowing in the duodenum and gastric outlet obstruction. Patient often presents with severe vomiting.
References
- ↑ "ATLAS OF PATHOLOGY". Retrieved 2007-08-26.
- ↑ Cullen DJ, Hawkey GM, Greenwood DC; et al. (1997). "Peptic ulcer bleeding in the elderly: relative roles of Helicobacter pylori and non-steroidal anti-inflammatory drugs". Gut. 41 (4): 459–62. PMID 9391242.
- ↑ "Peptic Ulcer: Peptic Disorders: Merck Manual Home Edition". Retrieved 2007-10-10.
External links
- Pathology specimen of Gastric ulcer
- A case report and tutorial on perforated duodenal ulcer
- Causes of Peptic ulcers
Template:SIB Template:Gastroenterology
bs:Ulcerozne lezije želuca ca:Úlcera pèptica da:Mavesår de:Magengeschwür el:Έλκος it:Ulcera peptica nl:Maagzweer no:Magesår nn:Magesår sq:Ulçera në stomak simple:Peptic ulcer fi:Mahahaava sv:Magsår