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Saturday, July 4, 2020

Peptic ulcer disease pathophysiology/Treatment for peptic ulcer

PEPTIC ULCER 


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 peptic ulcer disease definition :A peptic ulcer is an open sore in the upper digestive tract.Two types of peptic ulcers, 1. Gastric ulcer, which forms in the lining of the stomach, and 2.duodenal ulcer, which forms in the upper part of the small intestine. 

Introduction: In the digestive system, an ulcer is an area of open sores where tissue has been destroyed by the gastric juices and stomach acid. Peptic ulcer disease is a general/common term for ulcers that occur in the lining of the stomach or of the duodenum (upper part of the small intestine). 

  •  Most ulcers are known  to be link with Helicobacter pylori, a spiral-shaped bacterium that lives in the acidic environment of the stomach. 
  • Ulcers can also be caused by drugs such as Aspirin and other NSAIDS. About 4 % of gastric ulcers are caused by a malignant tumour, which is one of the reason to be vigilant in their detection. 
  • Duodenal ulcers are generally non-malignant. The places where the peptic ulcer may form are : Stomach (called gastric ulcer), Duodenum (called duodenal ulcer), Esophagus (called esophageal ulcer).
Etiology : Symptoms of a peptic ulcer includes Abdominal pain , Hematemesis ( vomiting of blood ) , Melena ( tarry , foul - smelling feces due to oxidised iron from hemoglobin ) . Weight loss . Rarely the ulcer can lead to a gastric or duodenal perforation . Heartburn , gastroesophageal reflux disease ( GERD ) and use of certain forms of medication can be the cause of peptic ulcer .

Medicines which can cause peptic ulcer includes : NSAID ( non - steroid anti - inflammatory drugs ) which act by inhibiting cyclooxygenase , and most glucocorticoids ( eg , dexamethasone and prednisolone ) . 

The symptoms by which one can differentiate between gastric and duodenal ulcers are ; A gastric ulcer would give epigastric pain during the meal due to the secretion of gastric acid , or after the meal where the alkaline duodenal contents reflux into the stomach Symptoms of duodenal ulcers could be seen mostly before the meal when the acid production is stimulated by hunger and is passed into the duodenum

Pathophysiology : A primary or major  causative component (. 90% of duodenal , 75% of gastric ulcer ) is chronic inflammation because of  Helicobacter pylori, spirochaete that inhabits the antral mucosa and increases gastrin production which in turn stimulates the production of gastric acid by parietal cell. 


A major cause is the use of NSAIDS. The gastric mucosa protects a layer of mucous from gastric acid which is stimulated by certain prostaglandins. 


block the function of cyclooxygenasel (cox-1), which is essential for the production of these prostaglandins. Stress in the psychological sense has not been proved to influence the growth of peptic ulcers. 



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Macroscopically: gastric ulcer is mostly localized on the lesser curvature of the stomach.   It is a round to oval, 2 to 4 cm diameter, with a smooth base and perpendicular borders.   Surrounding mucosa may present radial folds, as a outcome of the parietal scarring. 

Microscopically: During the active phase, the base of the ulcer shows / demonstrate 4 zones :  inflammatory exudate, granulation tissue and fibrous tissue, fibrinoid necrosis.  (g.p.u.)gastric peptic ulcer is a mucosal defect which penetrates the muscularis mucosae and muscularis propria, produced by acid-pepsin attack. 

Peptic ulcer diagnosis

Diagnosis: The test is esophagogastroduodenoscopy (EGD), a form of endoscopy where the location and severity of an ulcer can be visually seen. The diagnosis of Helicobacter pylori çan be by: Biopsy during EGD Breath testing) direct culture from an EGD biopsy specimen direct detection of urease activty in a biopsy specimen, 

Treatment for peptic ulcer : Younger patients with ulcer-like symptoms are often treated with  H2 antagonists or antacids When Helicobacter pylori infection is present, the most effective treatments are combinations of 2 antibiotics E.g.   Amoxicillin, Tetracycline, Ampicillin Erythromycin  Metronidazole  and 1 proton pump inhibitor (PPI). An effective combination would be  Metronidazole + Amoxicillin + Pantoprazole (a PPI). In the absence of H. pylori, long-term higher dose PPIS are often used.

Treatment of Helicobacter usually leads to eventual healing of ulcers clearing of infection, and relief of symptoms   Recurrence of infection can occur and retreatment may be required, with other antibiotics

 


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