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Peptic Ulcer Disease




Condition characterized by

Erosion of GI mucosa resulting from

digestive action of HCl and pepsin




Ulcer development

Loer esophagus

!tomachDuodenum

"#$ of men% &$ of omen



'ypes

(cute

!uperficial erosion

)inimal erosionChronic

)uscular all erosion ith formation

of fibrous tissuePresent continuously for many months

or intermittently



Peptic Ulcer Disease Etiology and Pathophysiology

Develop only in presence of acidenvironment

E*cess of gastric acid not necessary for

ulcer developmentPerson ith a gastric ulcer has normal to

less than normal gastric acidity

compared ith person ith a duodenalulcer




!ome intraluminal acid does seem to be

essential for a gastric ulcer to occur

Pepsinogen is activated to pepsin in

presence of HCl and a pH of + to ,

!ecretion of HCl by parietal cells has a

pH of #-.

pH reaches + to , after mi*ing ith

stomach contents




)ucosal barrier prevents bac0 diffusion

of acid from gastric lumen through

mucosal layers to underlying tissue

)ucosal barrier can be impaired and

bac0 diffusion can occur



1ac02Diffusion of (cids

3ig- &#2",




HCl freely enters mucosa hen barrier is

bro0en

In4ury to tissue occurs

5esult6 cellular destruction and

inflammation




Ulcerogenic drugs inhibit synthesis of

prostaglandins and cause abnormal

permeability

Corticosteroids 9 rate of mucosal cell

reneal thereby 9 protective effects



Disruption of Gastric )ucosal 1arrier

3ig- &#2"&




:hen blood flo is not sufficient% tissue

in4ury results




'o mechanisms that protect

)ucus forms a layer that entraps or

slos diffusion of hydrogen ions across

mucosal barrier

1icarbonate is secreted;eutralizes HCl acid in lumen of GI tract




8 7agal nerve stimulation results in

hypersecretion of HCl acid

8 HCl acid can alter mucosal barrier

Duodenal ulcers are associated ith 8

acid



Gastric Ulcers

Commonly found on lesser curvature in

close pro*imity to antral 4unction

Less common than duodenal ulcers

Prevalent in omen% older adults%

persons from loer socioeconomic

class



Gastric Ulcers

Characterized by

( normal to lo secretion of gastric

acid

1ac0 diffusion of acid is greater

<chronic=



Gastric Ulcers

Critical pathologic process is amount of

acid able to penetrate mucosal barrier

H. pylori is present in /#$ to >#$



Gastric Ulcers

H. pylori is thought to be moredestructive hen no*ious agents areused% or patient smo0es



Gastric Ulcers

Drugs can cause acute gastric ulcers(spirin% corticosteroids% ;!(IDs%

reserpine

?r 0non causative factorsChronic alcohol abuse% chronic gastritis



Duodenal Ulcers

?ccur at any age and in anyone

8 1eteen ages of ,/ to &/ years

(ccount for @.#$ of all peptic ulcers



Duodenal Ulcers

(ssociated ith 8 HCl acid secretion

H. pylori is found in A#2A/$ of patientsDirect relationship has not been found



Duodenal Ulcers

Diseases ith 8 ris0 of duodenal ulcers

C?PD% cirrhosis of liver% chronic

pancreatitis% hyperparathyroidism%

chronic renal failure

'reatments used for these conditions may

promote ulcer development



Psychological !tress Ulcers

(cute ulcers that develop folloing a

ma4or physiologic insult such as trauma

or surgery

( form of erosive gastritis



Psychological !tress Ulcers

Ischemia due to 9 capillary blood flo or

shunting of blood aay from GI tract so

that blood flo bypasses gastric mucosa

Imbalance beteen destructive

properties of HCl acid and pepsin% and

protective factors of stomachBs

mucosal barrier



Peptic Ulcer DiseaseClinical Manifestations

Common to have no pain or othersymptomsGastric and duodenal mucosa not rich

in sensory pain fibersDuodenal ulcer pain

1urning% crampli0e

Gastric ulcer pain1urning% gaseous



Peptic Ulcer DiseaseComplications

, ma4or complications

Hemorrhage

PerforationGastric outlet obstruction

Initially treated conservatively

)ay reuire surgery at any time duringcourse of therapy



Peptic Ulcer Disease Hemorrhage

)ost common complication of peptic

ulcer disease

Develops from erosion of

Granulation tissue found at base of

ulcer during healing

Ulcer through a ma4or blood vessel



Peptic Ulcer Disease Perforation

)ost lethal complication of peptic ulcer

Commonly seen in large penetratingduodenal ulcers that have not healed andare located on posterior mucosal all




Perforated gastric ulcers often located onlesser curvature of stomach




Perforation

3ig- &#2"/




?ccurs hen ulcer penetrates serosalsurface!pillage of their gastric or duodenal

contents into peritoneal cavity!ize of perforation directly proportional

to length of time patient has had ulcer

!udden% dramatic onset



Peptic Ulcer DiseaseGastric Outlet Obstruction

Ulcers located in antrum and prepyloricand pyloric areas of stomach

Duodenum can predispose to gastric

outlet obstruction 8 contractile force needed to empty

stomach results in hypertrophy of

stomach all




(fter longstanding obstruction stomachenters decompensated phase

5esults in dilation and atony




?bstruction is not totally due to fibrousscar tissue(ctive ulcer formation is associated

ith edema% inflammation%pylorospasm

(ll contribute to narroing of pylorus




Usually has a history of ulcer pain

!hort duration or absence of pain

indicative of a malignant obstruction




7omiting is common

Constipation is a common complaint

Dehydration% lac0 of roughage in diet

)ay sho selling in upper abdomen



Peptic Ulcer Disease Diagnostic Studies

Endoscopy procedure most often used

Determines degree of ulcer healing

after treatment

'issue specimens can be obtained to

identify H. pylori and to rule out

gastric cancer




Gastric analysis

Identifying a possible gastrinoma

Determining degree of gastric

hyperacidity

Evaluating results of therapy




Laboratory analysis

C1C

Urinalysis

Liver enzyme studies

!erum amylase determination

!tool e*amination

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