Peptic ulcer can occur either in the stomach or the first part of the small intestine called duodenum. An ulcer in the stomach is termed gastric ulcer or stomach ulcer, whereas an ulcer in the duodenum is termed duodenal ulcer. There is a bit of difference between the clinical presentation of these two types of peptic ulcer and a very good clinician should be able to determine which type of ulcer he is dealing with on presentation. The causes, diagnosis and treatment of both ulcers are similar.
Peptic ulcers occur when the highly acidic gastric juice secreted by the stomach begins to corrode the lining of the stomach or duodenum. These ulcers can be effectively treated after a few weeks of drug regimen, although in time past, before the 20th century, treating peptic ulcers required surgery and was associated with a high incidence of mortality.
The stomach and duodenum have a natural defence mechanism by which they are protected against the corrosive effects of the gastric juice. However, when this defence mechanism is disrupted, it predisposes the epithelial lining of the stomach and duodenal wall to acidic erosion which results in ulcers. Preventing the factors that can disrupt the defence mechanism is the key to guarding against peptic ulcer disease.
Gastric ulcers or stomach ulcers Occur when the thick layer of mucus that protects the stomach from the digestive juice released by the stomach is reduced. This allows the digestive juice to eat away the tissues that line the stomach wall which causes ulcer. Gastric ulcers are less common than duodenal ulcers.
Differential Clinical Features of Gastric Ulcer
The specific or differential clinical features that can be used to distinguish gastric ulcers from duodenal ulcers are
- The pain is located in the left epigastrum (just below the sternum).
- The pain is related to meals and present after eating meals.
- There pain in gastric ulcers is relieved by taking antacid or drinking milk.
- There is delayed gastric emptying of stomach content.
- If ulcer is located in the greater curvature of the stomach and severe, there is likeliness to see weight loss in the patient.
The duodenum is the most common site for peptic ulcers. They are about 4 times more common than gastric ulcers and occur when the corrosive gastric secretions erode the lining of the duodenal wall as food passes through it.
The differential clinical features of duodenal ulcers from gastric ulcers are
- In most people (about 50%), there is no pain felt.
- If pain is present, the pain is localised in the right epigastrum.
- The pain comes when one is hungry and it can wake the patient from sleep at night.
- The pain is relieved after eating food.
- There is increased gastric emptying of stomach content.
Additional Symptoms of Both Gastric and Duodenal ulcers
- Poor appetite
- Acid reflux
- Hematemesis (blood in vomitus)
- Melena (dark coloured stools)
- Anaemic symptoms
The causes of gastric and duodenal ulcers are the same.
Helicobacter pylori (H. Pylori) is the most common cause of both gastric and duodenal ulcers accounting for about 80% to 90% of all the cases. This bacteria is the root cause of the ulcers and until they are completely eradicated from the stomach, the patient will continue to have symptoms. H. Pylori can be spread through contaminated food or water.
Other causes and risk factors include
- Medications, specifically non-steroidal anti-inflammatory drugs (NSAIDs) like aspirin, ibuprofen, diclofenac and naproxen use for a prolonged period.
- Smoking and excessive alcohol drinking have been associated with developing stomach and duodenal ulcers especially with concomitant H. Pylori infection.
- Physical and mental stress are risk factors for peptic ulcers.
- Hypersecretory disorders of gastric juice (Zollinger-Ellison Syndrome) can cause ulcers, although very rarely.
- Genetics have been linked as a risk factor for developing peptic ulcers.
The clinical process of diagnosing gastric and duodenal ulcers involve
- Presenting clinical features.
- H. Pylori test. This can be carried out with blood or stool sample. A “breath test” for H. Pylori is also available.
- Barium swallow.
- Endoscopy of the esophagus, stomach and duodenum called esophagogastroduodenoscopy (EGD) is the best method of assessing site of ulceration and active bleeding.
- Endoscopic biopsy can be done to rule out stomach cancer.
If H. Pylori has been confirmed as the cause of the ulcer, antibiotics regimen is the treatment of choice involving a combination of potent antibiotics.
For causes of ulcer aside, H. Pylori infection, the use of proton pump inhibitors like omeprazole and rabeprazole are indicated. Antacid like mixed magnesium and aluminium salts may also be prescribed.
It is important for the patient to stop any current use of NSAIDs and desist from them. Alcohol intake and smoking should be advised against.
- Gastrointestinal bleeding : is the most common complication and occurs when the ulcer erodes the blood vessels on the mucosal wall such as the gastrointestinal artery. This sudden large bleeding can be life threatening.
- Perforation : A hole in the wall if the guy can result if the ulcers are left untreated. Erosion if the gastrointestinal wall can lead to a spillage of the stomach or intestinal content into the abdominal cavity which can result in peritonitis.
- Penetration : This is a form of perforation in which the hole created continues and the ulcer eats into adjacent organs like liver and pancreas.
- Gastric outlet obstruction : is the narrowing of the pyloric canal by scarring and swelling of the gastric Antrum and duodenum due to peptic ulcers. The person presents with severe vomiting without bile.
- Cancers : is included in the differential diagnoses and elucidated by biopsy. H. Pylori makes it 3 to 4 times more likely to develop stomach cancer from stomach ulcers.