A peptic ulcer, also known as ulcus pepticum, PUD or pepticulcer disease, is an ulcer (defined as mucosal erosions equal to or greaterthan 0.5 cm) of an area of the gastrointestinal tract that is usuallyacidic and thus extremely painful. As many as 80% of ulcers are associated withHelicobacter pylori, a spiral-shapedbacterium that lives in the acidic environment of the stomach, however only 40%of those cases go to a doctor. Ulcers can also be caused or worsened by drugssuch as aspirinand other NSAIDs.
Contrary to general belief, more peptic ulcers arise in the duodenum (firstpart of the small intestine, just after the stomach) than inthe stomach.About 4% of stomach ulcers are caused by a malignanttumor, so multiple biopsies are needed to exclude cancer. Duodenal ulcers aregenerally benign.
Signs and symptoms
Symptoms of a peptic ulcer can be
- abdominal pain, classically epigastric with severity relating to mealtimes, after around 3 hours of taking a meal (duodenal ulcers are classically relieved by food, while gastric ulcers are exacerbated by it)
- bloating and abdominal fullness
- waterbrash (rush of saliva after an episode of regurgitation to dilute the acid in esophagus)
- nausea, and copious vomiting
- loss of appetite and weight loss
- Hematemesis (vomiting of blood); this can occur due to bleeding directly from a gastric ulcer, or from damage to the esophagus from severe/continuing vomiting.
- melena (tarry, foul-smelling feces due to oxidized iron from hemoglobin);
- Rarely, an ulcer can lead to a gastric or duodenal perforation. This is extremely painful and requires immediate surgery.
A history of heartburn, Gastroesophageal reflux disease(GERD) and use of certain forms of medication can raise the suspicion forpeptic ulcer. Medicines associated with peptic ulcer include NSAID (non-steroidanti-inflammatory drugs) that inhibit cyclooxygenase,and most glucocorticoids (e.g. dexamethasoneand prednisolone).
In patients over 45 with more than two weeks of the above symptoms, theodds for peptic ulceration are high enough to warrant rapid investigation byEGD (see below).
The timing of the symptoms in relation to the meal may differentiatebetween gastric and duodenal ulcers:
A gastric ulcer would give epigastric pain duringthe meal, as gastric acid is secreted, or after the meal, as the alkaline duodenal contents reflux intothe stomach.Symptoms of duodenal ulcers would manifest mostly before the meal when acid (production stimulated by hunger) ispassed into the duodenum.However, this is not a reliable sign in clinical practice.
- Gastrointestinal bleeding is the most common complication. Sudden large bleeding can be life-threatening. It occurs when the ulcer erodes one of the blood vessels.
- Perforation (a hole in the wall) often leads to catastrophic consequences. Erosion of the gastro-intestinal wall by the ulcer leads to spillage of stomach or intestinal content into the abdominal cavity. Perforation at the anterior surface of the stomach leads to acute peritonitis, initially chemical and later bacterial peritonitis. The first sign is often sudden intense abdominal pain. Posterior wall perforation leads to pancreatitis; pain in this situation often radiates to the back.
- Penetration is when the ulcer continues into adjacent organs such as the liver and pancreas.
- Scarring and swelling due to ulcers causes narrowing in the duodenum and gastric outlet obstruction. Patient often presents with severe vomiting.
- Pyloric stenosis