PEPTIC ULCER DISEASE

What is Peptic Ulcer Disease? A peptic ulcer is an open sore or raw area on the inside surface of the stomach (gastric ulcer) or on the first part of the duodenum, part of the small intestine (duodenal ulcer). The average size of most of these ulcers is between half a centimeter to a centimeter in diameter. Peptic ulcer disease, or PUD, occurs when there is insufficient protection from the acid produced in the stomach for digestion. Protective factors include mucus which functions as a mechanical barrier to the acid, bicarbonate which is basic and therefore functions to neutralize the acid, and prostaglandins, hormone-like substances which allow adequate blood flow to the stomach, protecting it from any damage.

What Causes PUD? In the past, it was commonly believed that PUD was caused by high stress or a poor diet. It is now believed that these do not cause PUD but can aggravate PUD. The most common cause of PUD is due to a bacterial infection in the stomach from Helicobacter pylori (H. pylori). In fact, 90% of people with duodenal ulcers and 50% of people with gastric ulcers, have H. pylori. This bacterial infection is most commonly acquired in childhood through the fecal-oral route. There are at least two theories as to how H. pylori causes the lining of the stomach or duodenum to erode. Some believe that it produces toxins which cause inflammation and death of the cells in the stomach and duodenum, leading to ulcers. Others believe that the bacteria cause an increase in acid production, which then leads to the acid overcoming the stomach's protective factors, resulting in a ulcer. The second most common cause of PUD is the long term use of non-steroidal anti-inflammatory drugs (NSAIDs) such as aspirin, ibuprofen (Advil), and naproxen (Aleve, Naprosyn), and many others. These drugs are best avoided if you have a history of gastric problems. A third, and rare cause of PUD is Zollinger-Ellison Syndrome, caused by a tumour of the pancreas which affects acid-secretion in the stomach.

What Are The Signs And Symptoms Of PUD? The most common symptoms of PUD are local or diffuse abdominal pain, discomfort, heartburn, nausea, regurgitation, bloating, fullness and belching. The symptoms can be intermittent or constantly present. These symptoms often occur one to three hours after a meal. Eating some food can relieve the pain of duodenal ulcers but not the pain from gastric ulcers. PUD can also produce fatigue and shortness of breath if the ulcer starts to bleed. You should go to the Emergency Room immediately if you experience severe abdominal pain, if you are vomiting blood or coffee ground-like material or have black or bloody stools.

With What Can PUD Be Confused? Some of the same symptoms found in PUD can be caused by gastroesophageal reflux disease (GERD), gastritis and stomach cancer. Therefore, it is important to consult with your doctor if you are experiencing any of the signs and symptoms mentioned above. Tests that can be used to distinguish between PUD and these disorders include barium meal X-ray examination, fiberoptic endoscopy and tests for the presence of H. pylori. In fiberoptic endoscopy, a special tube fitted with an optical system is passed down the esophagus into the stomach. This permits visualization of the inside of the stomach and also the obtaining of a biopsy for examination by a pathologist in order to confirm the diagnosis of PUD. Fiberoptic endoscopy is currently the gold standard test for the diagnosis of PUD.

What Can You Do For PUD? Lifestyle changes include decreasing coffee (both caffeinated and decaffeinated), soft drinks, and consumption of alcohol, since these all increase acid secretion and can aggravate PUD. A high fibre diet which includes particularly apples, yams, celery, cranberries, and onions may be protective. Stress relief programs have not been shown to help ulcers heal. You should consult with your doctor since there are a number of medical interventions available for PUD. If you are taking any NSAIDs, the doctor can either stop the NSAIDs or modify your drug regimen in order to reduce the side effects of the NSAIDs. If the presence of H. pylori is confirmed, a mixture of antibiotics plus a drug that suppresses acid secretion (e.g. clarithro-mycin, metronidazole plus omeprazole) may be started to eradicate the bacteria. Omeprazole is a proton pump inhibitor (PPI), a class of drug that can reduce acid secretion to virtually zero; lansoprazole and pantoprazole are other members of this class. Antacids are drugs that neutralize acid; members of this class include aluminum hydroxide, magnesium hydroxide and magaldrate. Sucralfate is a cytoprotective agent, which helps counteract the damaging effects of excess acid and digestive enzymes on the lining of the stomach. Prostaglandins (see above) are believed to play a role in protecting the lining of the stomach from acid-mediated damage; misoprostol is an example of a drug of this class. Some preparations of NSAIDs have misoprostol added to them to offer protection against the irritating effects of NSAIDs on the stomach. Another class of drug that suppresses acid formation is the histamine H2-receptor antagonist; its members include cimetidine, famotidine, nizatidine, and ranitidine. Although certain of the above drugs can be obtained over the counter (OTC), it is important not to self-diagnose PUD or treat it indefinitely with OTC medications. Particularly in older people, the possibility of cancer of the stomach must be considered if acid indigestion persists for more than a few weeks and a physician should be consulted. Also, these drugs, like other drugs, have a variety of side effects that can result in problems if not taken under supervision. Formerly, various surgical procedures were widely used to treat patients with PUD. However, the use of surgery has dropped sharply since knowledge about the role that H. pylori plays has become available and also since the development of powerful drugs, such as the PPIs that can completely suppress secretion of acid by the stomach. At present, surgery is most likely to be used for the treatment of certain complications of PUD, such as perforation, hemorrhage and obstruction or if prolonged medical treatment has been unsuccessful.