Comprehensive Guide to Peptic Ulcers - Symptoms, Causes and Treatment Options

What is Peptic Ulcer Disease

Peptic ulcer disease (PUD) is a painful sore characterized by discontinuation in the inner mucosal lining of the gastrointestinal (GI) tract. This happens when the protective mucosal layer is eroded by gastric acid secretion or pepsin. The corrosion can extend to the third layer (muscularis; propria) of the gastric epithelium. Peptic ulcers mostly develop in the stomach and in the proximal duodenum. This underlies the two common type of peptic ulcers, which are Gastric Ulcers and Duodenal Ulcer (in the proximal duodenum). Erosion can also involve the jejunum, distal duodenum, and or the esophagus. The characteristics of epigastric pain distinguish these types of ulcers. Duodenal Ulcer, Epigastric pain usually occurs after 2 to 3 hours following meal, while gastric ulcers tends to occurs thin 15 to 30 minutes after meal. The bacterium Helicobacter Pylori (H. Pylori) is the most common cause of peptic ulcers and usually long use of Non-steroidal anti-inflammatory drugs (NSAIDs).

Risk factors of Peptic Ulcer

Several factors increase the likelihood of developing peptic ulcers, including:

• Helicobacter pylori infection
• Long-term use of NSAIDs
• Tobacco smoking
• Excessive Alcohol consumption
• Old Age and comorbidities
• Severe stress
• Eating seasoned or spicy foods
• Chronic conditions such as liver cirrhosis, chronic kidney disease, and diabetes
• Blood type A: Individuals with blood type O is at risk of developing stomach cancers, which increases risk for gastric ulcer.
• Blood type O: Individuals with blood type O tends to develop duodenal ulcer. This is because, O blood type do not produce the substance that protect duodenal lining.

Causes of Peptic Ulcer

Helicobacter pylori infection:The gram-negative bacterium H. Pylori is the most common cause of peptic ulcers. They disrupt the mucosal protective barrier, leading to inflammation and ulceration. Studies still don’t understand how people get infected with H. Pylori. But it is spread person to person through kissing, contaminated food or water. Infected person`s stool, vomitus, or saliva can also spread the infection.

Medications:Long use of over the counter medications such as NSAIDs (ibuprofen, naproxen sodium, ketoprofen) and aspirin can irritate and inflame the stomach lining. NSAIDs inhibit the production of the protective prostaglandins that repair damage to the gastrointestinal lining

Other causes include:

• Stress – psychological stress can exacerbate existing ulcers, or can disrupt the protective mechanisms of the stomach and increase acid production, resulting in stress-induced ulcer
• Other medications - potassium chloride, corticosteroids and bisphosphonates
• Crohn’s disease.
• Chemotherapy
• Radiation therapy.
• Zollinger-Ellison syndrome.
• Stomach cancer

Types of Peptic Ulcer

Gastric Ulcers:These ulcers occur when sore forms on the inner lining of the stomach. They are often associated with a slower healing process compared to duodenal ulcers. Gastric ulcers can be more serious, as they may sometimes indicate the presence of stomach cancer if they do not respond to treatment. Gastric pain may be aggravated by eating, usually 15 to 30 minutes. Therefore, a biopsy is often recommended for gastric ulcers to rule out malignancy

Duodenal Ulcers:These ulcers develop in the proximal duodenum (the upper part of the small intestine). Duodenal ulcers typically heal more quickly than gastric ulcers and are more common among all types. Common symptoms include epigastric pain often occurring a few hours after meals or during the night.

Esophageal ulcer:Esophageal ulcers develop when a sore form in the esophageal lining, often due to acid reflux, or gastroesophageal reflex disease (GERD). Symptoms include heartburn, difficulty swallowing, and chest pain.

Pathophysiology of Peptic Ulcer

Peptic ulcer disease develops from a variety of processes, with key contributors such as H. Pylori colonization, overuse of NSAIDs, and stresses. H. Pylori has contributed to significant cause of many ulcer cases. The gastrointestinal lining is protected by a mucosal barrier, which is maintained by cyclooxygenase-1 (COX-1). COX-1 is essential for the production of prostaglandins which stimulate the secretion of gastroduodenal mucus and bicarbonate, thereby protecting GI lining. Disrupting in this process predispose GI lining into direct contact with gastric acid and pepsin, leading to erosion and damage. Non-steroidal Anti-inflammatory Drugs (NSAIDs) inhibit the activity of COX-1, compromising the mucosal barrier and increasing susceptibility to injury. Disruption in the normal protective mucosal barrier result in decrease resistance to bacteria invasion, facilitating H. Pylori infection. In response to the infection, inflammatory cytokines, neutrophils and other substance activate are released, causing epithelial cell necrosis and damage to the protective mucus layer. Proliferation of H. Pylori results in overproduction of gastric acid, exacerbate the damage, exacerbating the mucosal damage and contributing to ulcer formation.

Signs & Symptoms of Peptic Ulcer

Epigastric pain is the most common symptoms of peptic ulcer diseases reported. With gastric ulcers, pain worsen shortly after ingestion of food, thus between 15 to 30 minutes, when gastric juices are at their peak of work. On the other hand, Duodenal ulcers, pain usually occurs 2 to 3 hours following meal because, at this time, digestive juice enters the duodenum for further digestion. This pain also normally occurs during night, when you are asleep and can wake you up. Duodenal pain is sometime interpreted as hunger.

Aside epigastric pain, people usually do not notice symptoms but common symptoms of peptic ulcers include:

• Abdominal pain often described as a burning or gnawing sensation, typically occurring between meals or at night.
• Nausea and vomiting
• Loss of appetite
• weight loss
• fever and chills
• Bloating and belching, which may accompany pain
• Severe symptoms indicating complications
• Vomiting blood
• Black, tarry stools
• Pallor (paleness)
• Rapid heart rate
• Blood in stool
• Dizziness

Diagnostic Investigations & Test

Several investigations may be available to detect PUD and its specific type. But the most common ones include Upper GI series and Endoscopy. Other investigations and test include:

• History and physical examination
• H. Pylori antibodies test
• Esophagogastroduodenoscopy (EGD)
• X-rays
• Computed tomography (CT scan)
• Barium swallow
• Full blood count (FBC)
• Liver function test (LFT)
• Amylase and lipase level test
• Stool antigen test

Treatment of Peptic Ulcer

Eradicating the bacterium H. Pylori is crucial. The primary goals of peptic ulcer management are to relieve symptoms, promote healing, and prevent complications. Treatment may include:

• Medications to protect the gastrointestinal lining - Misoprostol (Cytotec) and Sucralfate (Carafate). These medications are called cytoprotective agents.
• Proton pump inhibitors (PPIs): PPIs block stomach acid production. Examples include; Omeprazole, Esomeprazole, Pantoprazole, Or Lansoprazole
• Antacids: Antacids neutralizes the stomach acid to relieve acid indigestion and heartburn. Examples of antacids includes Magnesium Hydroxide and Calcium Carbonate. Antacids are prescribed orally.
• Histamine 2 receptor blockers (H2). H2 blockers reduce the level of acid the stomach produces. They include Cimetidine (Tagamet), Famotidine (Pepcid), Nizatidine (Axid), and Ranitidine.
• Antibiotics: If H. pylori is the underlying cause, a combination of antibiotics and acid-reducing medications is usually recommended. Antibiotic includes Metronidazole (Flagyl), Tetracycline (Achromycin V), Amoxicillin (Amoxil), Clarithromycin (Biaxin).
• Lifestyle modifications: Avoiding over the counter medication (Aspirin, NSAIDs), quitting smoking, limiting alcohol intake, and reducing stress can help manage and prevent peptic ulcers

In severe cases, peptic ulcers not responding to treatment for 12-16 weeks becomes life threatening and may require surgical interventions. Possible procedures include

• Pyloroplasty: Reconstructing the pylorus to widen or remove part of the muscles.
• Vagotomy: Vagotomy with or without pyloroplasty, this is transecting the nerves (Vagus) that’s stimulate acid secretion and opening the pylorus.
• Distal subtotal gastrectomy (Antrectomy): Antrectomy is the removal of antrum with anastomosis to either the duodenum (Billroth I or gastroduodenostomy) or jejunum (gastrojejunostomy or Billroth II).

Nursing Management of Peptic Ulcer

The following are the measures to put in place in the care of patient's with Peptic Ulcer

• Assess and record patient pain characteristics and report.
• Monitor vitals
• Review factors that aggravate or alleviate pain.
• Teach patient to identify aggravating factors such as food.
• Monitor patient hydration status
• Encourage small frequent meals at regular interval
• help patient to assume a comfortable position.
• Educate patient to avoid a diet rich in milk and creams, which are acid stimulants.
• Instruct patient to avoid aspirin NSAIDS and alcohol.
• Teach patient on lifestyle modifications
• Teach patient relaxing techniques to help reduce stress and pain
• Monitor patient for signs symptoms of perforation such as pain, bleeding, abdominal distention
• Administer prescribed medications
• Monitor patient for medications possible side effect

If surgery is required;

• Obtain informed consent
• Prepare for barium swallow
• Maintain NPO status
• Administer prescribed laxatives to clean the GI tract.
• Explain procedures to procedures
• Provide emotional support

Preventions of Peptic Ulcer

• To help prevent peptic ulcers, the following measures are recommended:
• Prompt treatment of H. Pylori infections can significantly reduce ulcer risk
• Limiting the use of over the counter medications help prevent risk
• Maintaining a balanced diet
• Managing stress
• Avoiding or quit smoking
• Avoid excessive alcohol consumption