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Peptic Ulcer – Classification, pathophysiology, sign and symptoms

CLASSIFICATION OF ULCERS

GASTRIC ULCERS

  • Incidence: Usually 50 and over
  • Male: female ratio 1:1
  • 15% of peptic ulcers are gastric
  • Signs, Symptoms, and Clinical Findings
  • Normal—hyposecretion of stomach acid (HCl)
  • Weight loss may occur
  • Pain occurs 1⁄2 to 1 hour after a meal
  • may be relieved by vomiting; ingestion of food does not help, sometimes increases pain
  • Vomiting common
  • Hemorrhage more likely to occur than with duodenal ulcer; hematemesis more common than melena
  • Risk Factors
  • pylori, gastritis, alcohol, smoking, use of NSAIDs, stress

DUODENAL ULCERS

  • Incidence: Age 30–60
  • Male: female ratio 2–3:1
  • 80% of peptic ulcers are duodenal
  • Signs, Symptoms, and Clinical Findings
  • Hypersecretion of stomach acid (HCl)
  • May have weight gain
  • Pain occurs 2–3 hours after a meal
  • ingestion of food relieves pain
  • Vomiting uncommon
  • Hemorrhage less likely than with gastric ulcer, but if present melena more common than hematemesis
  • More likely to perforate than gastric ulcers
  • Malignancy Possibility
  • Rare
  • Risk Factors
  • pylori, alcohol, smoking, cirrhosis, stress

ZOLLINGER ELLISON SYNDROME (ZES)

  • ZES consists of severe peptic ulcers, extreme gastric hyperacidity, and gastrin-secreting benign or malignant tumors of the pancreas.
  • ZES is suspected when a patient has several peptic ulcers or an ulcer that is resistant to standard medical therapy.
  • It is identified by the following findings: hypersecretion of gastric juice, duodenal ulcers, and gastrinomas (islet cell tumors) in the pancreas.

STRESS ULCERS

  • Stress ulcer is the term given to the acute mucosal ulceration of the duodenal or gastric area that occurs after physiologically stressful events, such as burns, shock, severe sepsis, and multiple organ traumas.
  • These are clinically different from peptic ulcer. These ulcers are most common in ventilator-dependent patients after trauma or surgery.
  • Fiberoptic endoscopy within 24 hours after injury reveals shallow erosions of the stomach wall; by 72 hours, multiple gastric erosions are observed. As the stressful condition continues, the ulcers spread. When the patient recovers, the lesions are reversed. This pattern is typical of stress ulceration.
  • Stress ulcers should be distinguished from Cushing’s ulcers and Curling’s ulcers, two other types of gastric ulcers. Cushing’s ulcers are common in patients with trauma to the brain. They may occur in the esophagus, stomach, or duodenum and are usually deeper and more penetrating than stress ulcers. Curling’s ulcer is frequently observed about 72 hours after extensive burns and involves the antrum of the stomach or the duodenum.

ESOPHAGEAL ULCERS

Esophageal ulcers occur as a result of the backward flow of HCl from the stomach into the esophagus (gastroesophageal reflux disease [GERD]).

PATHOPHYSIOLOGY

Peptic ulcers occur mainly in the gastroduodenal mucosa because this tissue cannot withstand the digestive action of gastric acid (HCl) and pepsin.

The use of NSAIDs inhibits the secretion of mucus that protects the mucosa.

Patients with duodenal ulcer disease secrete more acid than normal, whereas patients with gastric ulcer tend to secrete normal or decreased levels of acid.

Ninety percent of tumors are found in the “gastric triangle,” which encompasses the cystic and common bile ducts, the second and third portions of the duodenum, and the neck and body of the pancreas. Approximately one third of gastrinomas are malignant.

CLINICAL MANAFESTATIONS

Abdominal discomfort is the most common symptom of both duodenal and gastric ulcers. Felt anywhere between the navel and the breastbone, this discomfort usually

  • is a dull or burning pain
  • occurs when the stomach is empty—between meals or during the night
  • may be briefly relieved by eating food, in the case of duodenal ulcers, or by taking antacids, in both types of peptic ulcers
  • lasts for minutes to hours
  • comes and goes for several days or weeks

Other symptoms include

  • weight loss
  • poor appetite
  • bloating
  • burping
  • nausea
  • vomiting

Some people experience only mild symptoms or none at all.

Emergency Symptoms

A person who has any of the following symptoms should call a doctor right away:

  • sharp, sudden, persistent, and severe stomach pain
  • bloody or black stools
  • bloody vomit or vomit that looks like coffee grounds

These “alarm” symptoms could be signs of a serious problem, such as

  • bleeding—when acid or the peptic ulcer breaks a blood vessel
  • perforation—when the peptic ulcer burrows completely through the stomach or duodenal wall
  • obstruction—when the peptic ulcer blocks the path of food trying to leave the stomach

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