Peptic ulcer disease: Pathogenesis, clinical features, investigation, management, complications

1. PEPTIC ULCER DISEASE
Pukar K.C
Kathmandu University School of Medical Sciences

2. Normal
Esophagus & Stomach

3. DEFINITIONS
 Ulcer
Breach in the mucosa of the GI tract that extends through
the muscularis mucosa into submucosa or deeper
 Erosion
Epithelial disruption without breach of the muscularis
mucosa
 Peptic Ulcer disease
Circumscribed ulcer that occurs in any part of the GI tract
due to the aggressive action of acid and peptic juices.

4. SITES OF ULCERS
 First part of
Duodenum
 Lesser curve of
stomach
 Stoma following
gastric surgery
 Oesophagus
 Gastric mucosa within
Meckel’s Diverticulum

5. ETIOLOGY
 Helicobacter pylori infection
 Chronic NSAIDs and Corticosteroids use
 Cigarette smoking
 Alcohol consumption
 Zolinger-Ellison syndrome
 Hyperparathyroidism and chronic renal failure

6. PATHOGENESIS

7.  Zollinger- Ellison syndrome
 Uncontrolled secretion of gastrin by tumor resulting
massive acid production
 NSAIDs use
 Direct chemical irritation
 Suppressing prostaglandin synthesis
 Cigarette smoking
 Impaired mucosal blood flow and healing
 Hyperthyroidism and chronic renal failure
 Hypercalcemia induced excessive gastrin secretion

8. H. PYLORI
 Flagella
 Urease
 Generates ammonia from endogenous urea and
elevates pH
 Adhesins
 Enhance bacterial adherance to surface cells
 Toxins
 CagA gene

9. H. PYLORI

10. ETIOLOGIC FACTORS OF PUD

11. Features Gastric ulcers Duodenal ulcers
Incidence Less common More common
Common Location Antrum, lesser cuvature Anterior wall*, 1st part
Age group Middle age Middle or old age
Male: Female ratio 1:1 4:1
Association with H.
Pylori
65% 85%-100%
Level of gastric acid
secretion
Mostly normal Mostly increased
Malignancy Common Rare
*Kissing ulcers: Both anterior and posterior wall ulcer of
duodenum

12. TYPES OF GASTRIC ULCER
DAINTREE JOHNSON
•Type I
In the antrum, near lesser
curvature
Normal acid level
•Type II
Combined gastric and
duodenal ulcer
High acid level
•Type III
Prepyloric
High acid level
•Type IV
Ulcer in the proximal
stomach and Cardia
Normal acid level
55% 25%
15% 5%

13. FEW MORE ULCERS!!!
 Stress ulcer
 In association with shock, sepsis or severe trauma
 Curling ulcer
 In association with severe burns or trauma
 Cushing’s ulcer
 In patients with intracranial disease oor after
neurosurgery

14. CLINICAL PRESENTATION
 Symptoms
 Pain
 Epigastric region, burning or aching type
 May radiate to back
 Heartburn, Nausea, vomiting, bloating, belching, water-
brash
 Alteration in weight
 Haematemesis or Maelena  presents as anemia
 Periodicity of symptoms
 Significant past history
 Clinical examination
 Tender epigastrium
 Features of complication, if present

15. Gastric Ulcer Duodenal Ulcer
Pain increased after food intake Pain relieved after food intake
Periodicity less common Periodicity more common
Haematemesis more common Melaena more common
Weight loss common Weight gain occurs
Equal in both sexes More in males

17. INVESTIGATIONS
 Esophagogastrodeodenoscopy (EGD)
 Barium swallow
 Urea Breath Testing

18. ESOPHAGOGASTRODEODENOSCOPY
It is fundamental that any gastric ulcer
should be regarded as being
Malignant, no matter how classically it
resemble a benign gastric ulcer
Multiple biopsies should be taken, as many
as 10 well targeted biopsies

19. ESOPHAGOGASTRODEODENOSCOPY
 Endoscopic procedure
 Visualizes ulcer crater
 Ability to take tissue biopsy to R/O cancer and
diagnose H. pylori

20. BENIGN GASTRIC ULCER
MUCOSAL
FOLDS
Converging folds
Margin Regular
Floor Granulation tissue in
floor
Edges NOT everted ,punched
Surrounding
Area
Normal
Size and
Extent
Small deep up to
muscle layer

21. MALIGNANT GASTRIC ULCER
MUCOSAL
FOLDS
Effacing Mucosal folds
Margin Irregular margin
Floor Necrotic Slough in the
floor
Edges Everted Edges
Surrounding
Area
Shows nodules, ulcers
and irregularities
Size and
Extent
Large and Deep

22. BARIUM SWALLOW
 Outpouching of ulcer crater beyond the gastric
contour (exoluminal)
 Overhanging mucosa at the margins of a benign
gastric ulcer, project inwards towards the ulcer
 Regular/ Round Margin of the Ulcer Crater
 Converging mucosal folds towards the base of ulcer
 STOMACH SPOKE WHEEL PATTERN
 HAMPTON LINE: A thin millimetric radiolucent line
seen at the neck of a gastric ulcer in barium studies
 Deformed or absent duodenal cap

23. HAMPTON LINE: A thin millimetric radiolucent line seen at
the neck of a gastric ulcer in barium studies
STOMACH SPOKE` WHEEL
PATTERN

24. TESTS FOR H. PYLORI
 Noninvasive tests
 Serum or whole blood antibody tests
Immunoglobin G (IgG)
Urea breath test
 Patient drinks a carbon-enriched urea solution
 Excreted carbon dioxide is then measured
 Invasive tests
 Biopsy of stomach
 Rapid urease test

26. COMPLICATION
•Hemorrhage
•Perforation
•Penetration
•Narrowing and obstruction

27. HEMORRHAGE
 Blood vessels damaged as ulcer
erodes into the muscles of
stomach or duodenal wall
 Coffee ground vomitus or occult
blood in tarry stools
 Posterior wall duodenal ulcer
 Arteries involved
 GASTRIC ULCER erode LEFT
GASTRIC VESSELS and
SPLENIC VESSELS
 DUODENAL ULCER erodes
GASTRODUODENAL artery

28. PERFORATION
 Can erode through the entire wall
 Spillage of gastric/duodenal content and bacteria
into peritoneum leading to peritonitis
 Mostly associated with NSAIDs ulcers
 Anterior wall duodenal ulcer

29. PENETRATION
 Ulcers may erode through the entire thickness of
the gastric or duodenal wall into adjacent
abdominal organs
 Can involve the pancreas, bile ducts, liver, and the
small or large intestine.
 The pancreas is the most common site of
penetration

30. NARROWING AND OBSTRUCTION
 Hour glass contracture
 Cicatricial contracture of lesser curvature ulcer, dividing
the stomach in two compartments
 Teapot deformity
 Cicatrisation and shortening of lesser curve
 Pyloric stenosis
 Scarring and cicatrisation of first part of duodenum
 Persistent vomiting

31. MANAGEMENT
 Non-pharmacological
 Pharmacological
 Surgical

32. PHARMACOLOGICAL MANAGEMENT
 Provide pain relief
 Antacids and mucosa protectors
 Eradicate H. pylori infection
 Two antibiotics and one acid suppressor
 Heal ulcer
 Eradicate infection
 Protect until ulcer heals
 Prevent recurrence
 Decrease high acid stimulating foods in susceptible people
 Avoid use of potential ulcer causing drugs
 Stop smoking
AIM

33. NON-PHARMACOLOGICAL
• Avoid spicy food.
• Avoid Alcohol.
• Avoid Smoking.
• Avoid heavy meals.
• Encourage small frequent low caloric meals.
• Avoid ulcerating drugs e.g. NSAIDs, corticosteroids

34. HYPOSECRETORY DRUGS
 Proton Pump Inhibitors
 Suppress acid production
 H2-Receptor
Antagonists
 Block histamine-stimulated
gastric secretions
 Antacids
 Neutralizes acid and
prevents formation of
pepsin
 Give 2 hours after meals
and at bedtime
 Prostaglandin Analogs
 Reduce gastric acid and
enhances mucosal
resistance to injury
 Mucosal barrier
fortifiers
 Forms a protective coat
 Sucralfate

35. MEDICAL TREATMENT

37. ERADICATION THERAPY
 Directed against H. pylori
 Regimens
 Triple therapy for 2 weeks
 Omeprazole 20 mg twice daily or lansoprazole 30 mg twice daily
or pantoprazole 40 mg twice daily or esomeprazole 40 mg daily or
rabeprazole 20 mg daily
 Clarithromycin 500 mg twice daily
 Amoxicillin 1 g twice daily
 Quadruple therapy for 2 weeks
 Omeprazole 20 mg twice daily or pantoprazole 40 mg twice daily
or esomeprazole 40 mg daily or rabeprazole 20 mg daily
 Bismuth subsalicylate 525 mg twice daily
 Metronidazole 250–500 mg three times daily
 Tetracycline 500 mg four times daily
 The PPIs should be continued for 6 more weeks

38. SURGERY
 Indication
 Complicated ulcers
 Not responding to medical treatment

39. TYPES OF SURGICAL PROCEDURES
2.Gastroenterostomy
allows regurgitation of alkaline duodenal
contents into the stomach
• Gastrojejunostomy
1.Diversion of Acid Away from
the duodenum
•Billroth II
3.Reduce the secretory Potential of
Stomach
•Billroth I (gastric ulcer)
•Truncal vagotomy and drainage
•Highly selective vagotomy
•Truncal vagotomy and antrectomy

40. BILLROTH I GASTRECTOMY
Gastric ulcers
Distal portion of the
stomach is mobilised
and resected
The cut edge of the remnant is partially
closed from Lesser Curvature aspect
Stoma at greater curvature aspect
Gastroduodenal anastomosis done

41. BILLROTH II GASTRECTOMY
The lower portion of the
stomach is removed along
with the ulcer and the
remainder is anastomosed
to the jejunum
Recurrent ulceration is low
High Operative Mortality and
Morbidity

42. SEQUELAE OF PEPTIC ULCER SURGERY
 Recurrent Ulceration
 Small Stomach
Syndrome
 Bile Vomiting
 Early and Late
Dumping
 Post Vagotomy
Diarrhoea
 Malignant
Transformation
 Nutritional
Consequences
 Gall Stones

43. OTHER TYPES OF ULCER
 NSAIDs induced ulcers
 Antisecretory agents
 Stomal ulcers
 Prolonged course of antisecretory agents
 Zollinger- Ellison syndrome
 Proton pump inhibitors unless tumor can be managed
by surgery

44. MANAGEMENT OF COMPLICATIONS