Peptic ulcer disease (gastric and duodenal ulcer)

Peptic ulcer is a general chronic and relapsing disease characterized by seasonal exacerbations with ulceration of the stomach wall or the duodenum. Approximately 10% of all adults have peptic ulcer at some time in their lives. Duodenal ulcer is more common 4 times than gastric ulcer. The male to female ratio for duodenal ulcer varies from 4:1 or 2:1. Gastric ulcer is more common in the older (over 50 year), and duodenal ulcer in those from 30-60 year. Duodenal ulcer is more common in male at age 30-55 years. 90-95% of duodenal ulcers occur in the first portion of duodenum. More than 90% of gastric ulcers occur in the lesser curvature.

Etiology

- associated with Helicobacter pylori;

- influence of drugs;

- results of pathological hypersecretion;

- mixed etiology.

Many ulcers are caused by a bacterium called Helicobacter pylori (H. pylori). Around 90% of duodenal ulcer patients and 70% of gastric ulcer patients are infected with H. pylori. Peptic ulcers frequently also can be caused by daily use of pain relievers called non-steroidal anti-inflammatory drugs (NSAIDs). The remaining 30% of gastric ulcers are due NSAIDs.

Having a close relative with peptic ulcer disease also increases your risk, as does smoking and alcohol use.

Pathogenesis

An ulcer forms when there is an imbalance between aggressive factors and defense factors. Aggressive factors: H. pylori infection, NSAIDs, acid and pepsin, smoking, alcohol and other factors. Defense factors: gastric mucosa, gastroprotective prostaglandins, mucus layer on epithelial cells, bicarbonate secreted by epithelial cells and adequate blood supply of gastric mucosa.

 

Cinical features

The leading symptom of peptic ulcer is abdominal pain. In peptic ulcer the pain is localized in epigastric region, may radiate to the back and is of variable quality: gnawing, burning, boring, or hunger like. The pain is intermittent, last from a few minutes to many hours, be worse when your stomach is empty. Food, antacids or other antisecretory drugs often bring relief. The seasonal character of pain is very typical of peptic ulcer disease.

In patients with peptic ulcer the main complaints are abdominal pain and displays of dyspeptic syndrome. Heartburn, vomiting, belching, regurgitation, and salivation are frequent symptoms. Vomiting relieves pain of gastric ulcer and some patients force themselves to vomit after eating to relieve symptoms. Heartburn is a specific burning sensation behind the sternum, associated with regurgitation of gastric contens into the inferior portion of lie esophagus. The mechanism of heartburn is associated with motor dysfunction of the esophagus (in addition to the acid fact of the gastric contents, which was formerly believed to be decisive). Appetite is often increased. The intestinal symptoms of peptic ulcer disease are constipations, which are closely connected with the character of nutrition and bed-rest during exacerbations, and are mainly connected with reflex dyskinesia of the intestine.

Objective examination. General patient's condition is usually from moderate grave to extremely grave. The consciousness is clear, the posture usually active or may be forced in cause of complications development. The color of the skin and visible mucosa has corporeal color. With disease progression and prolonged duration may occurs pale color and loss of weight. The tongue is usually clean. The data of inspection, palpation, percussion and auscultation of respiratory and cardiovascular systems are without peculiarities.

In superficial tentative oriental palpation and percussion of the abdomen may be distinguish pain in epigastrium and umbilical regions with local muscular resistance.

Additional methods of examination

Endoscopy (fibroesophagogastroduodenoscopia) is the procedure of choice for diagnosis of peptic ulcer. Endoscopy with biopsy and the subsequent morphological research of a bioptates - confirms presence of ulcer defect and specifies of its localization, depth, the form, the sizes, condition of the bottom and edges of the ulcer.

Barium meal (or X-ray examination). A direct proof of peptic ulcer is a niche, which is found in 75-80 per cent of patients. The ulcer is usually located on the lesser curvature. In duodenal ulcer, the can be found inside the bulb or outside it (extrabulbar ulcer). Barium meal is less commonly used now. Endoscopy should be done if it shows gastric ulcer to rule out malignancy.

Gastric secretory function. The main method of study of gastric secretion is pH-measure (intragastral pH-metria). Normal basal pH in body stomach is 1.6-2.2. There is pH more than 2.2 – hyperacidity. There is pH less than 1.6 – hypoacidity. If the ulcer is found in the stomach, hydrochloric acid, pepsin, mucoprotein and albumin fractions of the gastric juice vary within normal limits. In duodenal ulcer all these indices significance exceed normal values.

Determining of Helicobacter pylori. Blood test or Serological test - determine antibodies of H. pylori in blood. Breath test. You drink a solution that contains a radioactive carbon atom. If H. pylori is in your body, it will break down the solution and release the carbon. Your bloodstream carries the carbon to your lungs, where it's exhaled and can be detected in your breath. Stool test – determine antigen of H. pylori in feaces. H. pylori can be detected histologically on biopsy of gastric mucosa.

Rapid urease activity test. Culture. Biopsies obtained can be cultured on special medium.

Clinical blood analysis. May be determining of the signs of ferric deficiency anemia at chronic or acute bleeding.

Examination of faeces. Latent haemorrihage is almost always revealed on examination of faeces during exacerbation of peptic ulcer.

Complications

Haemorrhage. This is the most frequent complication. It may be manifested by haematemesis (blood vomiting) and tarry faeces (melaena). Among other causes of gastric haemorrhagel peptic ulcer is accounted for 15-25 per cent of patients. The patient general condition depends on the length and intensity of bleeding.

Perforation. Free perforation into peritonial cavity occurs in approximately 2-3% of patients. Signs of perforation are a sudden stabbing pain, the reflex collapse, acute abdomen, and progressive peritonitis (unless a timely surgical aid is given to the patient). The pain is felt beneath the xiphoid process or in the right hypochondrium. The abdominal wall is tense. The patient assumes a forced posture on his back; the tongue is dry and coated. The pulse is retarded.

Penetration. Extension of the ulcer crater beyond the gastric or duodenal wall into contiguous structure e.g. pancreas especially if ulcer is in posterior wall of duodenum. Less commonly ulcer may penetrate into liver, biliary tract or colon.

Stenosis or pyloric obstruction. Ulcers heal to leave scars. If the ulcer was in the pylorus, the cicatricial tissue may narrow the lumen and interfere with free passage of he gastric contents into the duodenum. First the narrowing is compensated for by hypertrophy of the gastric muscles, but later the stomach becomes distended, food stays inside it for a longer period. Patient presents with abdominal bloating, nausea, vomiting and weight loss. Patients complain of permanent pain, eructation with rotten egg wind, and profuse morning vomiting with food that was ingested several days ago. Constipation is alternated with diarrhea. In the presence pyloric stenosis peristaltic and antiperistaltic movements of the epigastrium can be seen.

IRRITABLE BOWEL SYNDROME

Functional gastrointestinal disorders are defined as disorders of gut function in the absence of structural pathology. Irritable bowel syndrome is a function bowel disorder in which abdominal pain is associated with defaecation or a change in bowel habit with features of disordered defaecation and distension.

Irritable bowel syndrome encompasses a wide range of symptoms and single cause is unlikely. It is generally believed that most patients develop symptoms in response to psychosocial factors, altered gastrointestinal motility, altered visceral sensation or luminal factors.

Clinical features

The most common presentation is that of recurrent abdominal pain. This is usually colicky or “cramping”, is felt in the lower abdomen and is relived by defaecation. Abdominal bloating worsens throughout the day; the cause is unknown but it is not due to excessive intestinal gas. The bowel habit is variable. Most patients alternate between episodes of diarrhea and constipation. The constipated type tend to pass infrequent pellety stools, usually in association with abdominal pain. Those with diarrhoea have frequent defaecation but produce low-volume stools. Passage of mucus is common.

Despite apparently severe symptoms, patients do not lose weight and are constitutionally well. Many have other “functional” symptoms including dyspepsia, headaches, backache, poor sleep and chronic fatigue syndrome. Physical examination does not reveal any abnormalities.

 

Literature

1. Internal diseases an introductory course. - Vasilenko V., Grebenev A. - M.: Mir. Publishers, 1990. - 647 p

2. Propedeutics to internal medicine. Part 1.-Vinnytsya: NOVA KNYHA, 2006.- 424 p.

3. Propedeutics to internal medicine. Part 2.-Vinnytsya: NOVA KNYHA, 2007.- 264 p.

4. Introduction to the course of internal diseases. Book 1. Diagnosis: [Textbook/Zh.D. Semidotskaya, O.S. Bilchenko, et al.].-Kharkiv: KSMU, 2005. -312p.

5. Michael Swash Hutchison’s clinical methods / XIX edition. ELBS, 1989. -618p.

6. Mark H., Beers M.D., Robert Berkow The Merck Manual of diagnosis and therapy / XVII edition.- Published by Merk research laboratories, 1999.- 2833 p.

7. Harrison΄s principles off internal medicine / Fauci, Braunwald, Isselbacher and al.-XIV edition. - Vol. 1 and 2. - International edition, 1998.

 

Topic 11. Basic Symptoms and Syndroms in Biliary Diseases: Chronic Cholecystitis, Cholangitis, Cholelithiasis.

Class lasts: 3 hours

Chronological class structure:

Control of initial standard of knowledges- 20 min.

Teacher′s demonstration of practical skills - 60 min.

Sudents′ independent work: - 30 min.

Control of ultimate standard of knowledges- 15 min.

Sum up of the class, homework- 10 min.

Questions for theoretical preparation: Definition and modern classifications of chronic cholecystitis and cholangitis. Biliary duct dyskinesia and its tapes. Main complaints of the patients with cholecystitis and cholangitis. Clinical, instrumental and laboratory examination of the patients for biliary disease. Study of duodenal contents and to analyze the results. Cholelithiasis.: main complaints and clinical features. Biliary pain (“biliary colic“). Jaundice and cholestasis, them laboratory findings.