Peptic Ulcer Disease

• Peptic Ulcer Disease means ulceration beyond muscularis mucosa in mucosa bath by acid and pepsin.

Ulcer Vs Erosion

• Ulcer extends beyond mucosa and heals by scar tissue.
• Erosion is limited to muscosa and heals by regeneration

Epidemiology

• Peptic Ulcer Disease occurs globally.
• Duodenal ulcers are more common in males due to the larger stomach and parietal cell mass.
• Gastric ulcers affect males and females equally.
• Duodenal ulcers typically occur between 20-40 years old .
• Gastric ulcers typically occur between 40-60 years old.
• Duodenal ulcers occur equally in high and low social classes.
• Gastric ulcers are more common in the low class.
• Duodenal ulcers are four times more common than gastric ulcers.
• Gastric ulcers are more common in the antrum and along the lesser curvature, and are associated with blood group A.
• Duodenal ulcers are more common in the first and upper part of the duodenum and are associated with blood group O.
• Posterior ulcers tend to bleed, which is the most lethal complication.
• Anterior ulcers tend to perforate, which is the most dramatic complication.

Cause and Pathophysiology of PUD

• The interaction between mucosa protectors and aggressors determines whether a PUD occurs.
• Aggressors include H. Pylori, NSAIDs, alcohol, smoking, bile reflux, and hyperacidity.
• Protectors include repair, acid control tight junctions, mucus-bicarb layer, and perfusion.
• PUD occurs when aggressors overrun protectors.
• Mucosa protection occurs via repair or restitution, tight junctions between epithelial cells, the mucus bicarb layer, acid control, and high perfusion.

Pathology

• Ulceration extends beyond the muscularis mucosa in mucosa that is bathed by acid in pepsin.
• PUD occurs in 5 locations: lower esophagus, stomach, duodenum, the jejunal side of a gastrojejunal stoma and in Meckel's Diverticulum.

Relevant Anatomy

• The stomach has several functions: receptive relaxation for food storage, digestion-churning with acid/pepsin production, propulsion forward, functioning as body armor with acid, production of intrinsic factor for B12 absorption, and activation of pepsin.

Relevant physiology of acid secretion

• Acid secretion is controlled by the receptors for histamine, acetylcholine, and gastrin located on the parietal/oxyntic cells.
• Other important secretions include pepsinogen from chief cells, mucus from mucus cells, and intrinsic factor.
• The vagal innervation is secreto-motor, its secretory function involves the cephalic phase of acid/juice production and its motor function involves receptive relaxation, peristalsis for gastric emptying, and functioning of the sphincter.

Presentation of PUD

• The precipitator is fasting or feeding.
• The quality of pain is peppery and burning.
• Pain can radiate to the back when penetrating the pancreas and may radiate to the right or left.
• Relief can occur by feeding (duodenal), vomiting (gastric with fear of feeding), antacids, or milk.
• The region of pain is epigastric.
• The severity is indicated if pain wakes the patient at midnight.
• There is diurnal variation and periodicity in its Timing.

Investigations

• Upper GI endoscopy allows direct visualization of the ulcer and makes biopsy & H. pylori testing possible, is the preferred diagnostic test,.
• An upper GI barium series can also be performed.

Complications

• Acute complications are perforation and bleeding.
• Subacute complications are peri-gastric and lesser sac abscess, penetration into the liver or pancreas, and inflammatory phlegmon that causes gastric outlet obstruction.
• Chronic complications are anemia and gastric outlet obstruction, which is caused by duodenal or antral stenosis, hourglass deformity, teapot deformity, malignant transformation, or kissing ulcers.

Differentiating Differentials

• Differential diagnoses include duodenal ulcer, gastric ulcer, cholelithiasis, hiatus hernia, GERD, carcinoma of the stomach, and acute pancreatitis (mild).

Treatment

• Treatment options include non-pharmacologic, pharmacologic (medical), and surgical interventions.

Pharmacologic Treatment options

• Antacids such as magnesium sulfate, aluminum hydroxide, and bicarbonate.
• Antimuscarinics such as atropine, pirenzipine, and probantelin
• H2-blockers such as cimetidine, ranitidine, and famotidine.
• Proton pump inhibitors like omeprazole and rabiprazole.
• Gastrin inhibitors like proglumide.
• Mucosa-protectors such as sucralfate, bismuth, and prostaglandin analogs like misoprostol.
• Anti-Helicobacter pylori treatment.

Surgical Treatment of Duodenal Ulcer

• Remove the innervation by vagotomy and ensure drainage by Pyloroplasty or gastrojejunostomy.
• Anthrectomy + billroth I or II anastomosis
• Combine them.

Surgical Treatment of Gastric Ulcer

• Remove the ulcer with or without reduction of acid production via wedge resection with vagotomy and bypass.
• Antrectomy.
• Distal partial gastrectomy.
• Subtotal gastrectomy.

Complications of Gastric Surgery for PUD

• Vagotomies can lead to gastroparesis-delayed emptying, post-vagotomy diarrhea, abdominal tuberculosis, pulmonary tuberculosis, bacterial overgrowth-malabsorption, phlegmonous gastritis, cholelithiasis, lesser curvature necrosis, recurrence, and colonic cancer.
• Gastric resection can result in short stomach syndrome, pernicious anemia, malnutrition, and malignant transformation.
• Drainage procedures may lead to anastomotic bleeding, anastomotic leakage, stoma obstruction (edema, stenosis), retrograde intussusception, early and late dumping syndrome, afferent loop syndrome, efferent loop syndrome, blind loop syndrome, gastrojejunocolic fistula, and reflux gastritis.

Clinical Application

• Managing a patient with abdominal pain suspected to be PUD includes assessing biodata, Pc, HPC, ROS, Pmhx, (o and G), Sohx, and Fhx.