04 Nov

Peptic ulcer disease

What is a peptic ulcer disease (PUD)?

Peptic ulcer disease (PUD) is defined as a disruption of the mucosal integrity of the gastric or duodenum due to inflammation, hyperacidity or reduced mucosa resistance. This condition may lead to the development of an ulcer.

Location of peptic ulcer disease

The most commonly affected site is the stomach and duodenum. Other sites include the distal oesophagus or jejunum but very rare.

What is the risk factor for peptic ulcer disease?

Peptic ulcer disease occurrence is associated with:

  • Helicobacter Pylori infection (common organism within the stomach. They are able to withstand the acidity of the stomach). Their presence within the gastric walls reduces the mucosal layers protection and increases the acidity.
  • NSAIDs remain one of the common risks in elderly. It is frequently taken for joints or back pain.
  • Smoking
  • Alcohol ingestion
  • Physical stress or illness may lead to the development of stress ulcers. It is commonly seen in ICU or critically ill patients.
  • Tumours such as gastric cancer or syndrome such as Zollinger Ellison syndrome.

Presentation

Epigastrium or upper abdomen pain
Heartburn or chest discomfort – need to rule out any myocardium infarction if high-risk patients
Dyspepsia symptoms

Investigation

Oesophagogastroduodenoscopy (OGDS) is the common procedure done to confirm the diagnosis and identify the presence of H. Pylori (using CLO test or biopsy).

  • This procedure involves insertion of a special endoscopy into the oesophagus and stomach.
  • Patients should be aware of the risk involved (bloating, perforation, bleeding, sedative effect.

A barium meal is also used to diagnose ulcers or tumours by looking at the x-ray films. However, in Malaysia, endoscopy remains the primary choice by most surgeons.

Other investigations include blood haemoglobin and renal profile, especially in active bleeding.

Treatment

The aim is to reduce the acidity and promote a healing ulcer. Medication is also used to eradicate H. pylori.
Besides medication, a patient should stop or reduce the risk factors.

Medical therapy

  • Proton pump inhibitor – reduces the acidity in the stomach. The increasing pH will stabilise the clot in a bleeding ulcer and promote healing. Example: Esomeprazole, Pantoprazole
  • H2 blocker – similar effect but a different mechanism of action. Example: ranitidine
  • Antibiotics are used to eradicate H. Pylori. Common antibiotics are Amoxicillin, Clarithromycin or Metronidazole (OAC or OAM regime).
    • previously Omeprazole is commonly used, hence the O in the regime. Any proton pump inhibitor can be used together with the antibiotics with similar efficacy.

Surgery

With the advancement of medical therapy, surgery is rarely needed. Previous surgery entails the cutting of the nerves supplying the stomach (vagotomy). This will reduce the acid production.

Other surgeries include partial or distal gastrectomy in cases on non-healing and malignant ulcers.

More information here

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