What is peptic ulcer disease?
Ulcers are breaks in the protective mucosal lining of the digestive tract that can vary in size (both in diameter and depth) and location.
What causes peptic ulcer disease?
Ulcers are the result of the breakdown of the mucosa, which may occur as a result of excessive gastric acid secretion. One common cause of peptic ulcer disease is infection with Helicobacter pylori bacteria. Non-steroidal anti-inflammatory drugs (NSAIDs) such as aspirin and ibuprofen can also contribute to mucosal injury of the upper digestive tract and lead to peptic ulcer disease.
What are the symptoms of peptic ulcer disease?
Common symptoms of peptic ulcer disease include abdominal discomfort, pain and nausea. The discomfort or pain is sometimes described as gnawing or burning. Antacids may give temporary relief. Gastric ulcer pain is usually aggravated by eating, especially spicy foods. Because eating causes pain, many patients with gastric ulcers avoid meals and consequently lose weight. Duodenal pain may be relieved by food. Patients with duodenal ulcer may have a weight gain.
How is peptic ulcer disease diagnosed?
Peptic ulcer disease is usually suspected in patients with gastric discomfort and pain. Several methods are available to confirm the diagnosis.
A barium X-ray or an upper GI series is a widely available and accepted method to establish a diagnosis of peptic ulcer disease in the stomach or duodenum. It is somewhat limited in that it is less sensitive and accurate in defining the exact nature of the disease or distinguishing benign from malignant ulcer disease and tissue sampling cannot be performed.
Esophagoduodenoscopy (EGD) is the most direct and most accurate method of establishing the diagnosis of peptic ulcer disease. In addition to identifying the ulcer, its location and size, EGD also provides an opportunity to detect and biopsy subtle mucosal lesions to determine the extent of damage. Endoscopic biopsies are indicated for all gastric ulcers because of the risk of underlying cancer, whereas duodenal ulcers are always benign and do not require biopsy.
Laboratory tests also play a role in diagnosing peptic ulcer disease. Blood tests or a urea breath test can determine whether H. pylori is present; gastric acid analysis can determine whether the ulcer is caused by gastric acid hypersecretion (basal acid output exceeding 10 mEq/hr) or decreased mucosal protection; serum gastrin and serum calcium levels can be measured to screen for gastrinoma and multiple endocrine neoplasia.
How is peptic ulcer disease treated?
Treatment for peptic ulcer disease centers around the reduction of hostile factors and increasing and augmenting protective factors. Specifically, the goal of therapy is to relieve symptoms, heal craters and prevent recurrences and complications. Medical therapy should include treatment with drugs and an attempt to accomplish the following:
- Eradicate the H. pylori infection
- Reduce gastric acidity by mechanisms that inhibit or neutralize acid secretion
- Coat ulcer craters to prevent acid and pepsin from penetrating to the ulcer base
- Provide a prostaglandin analogue
- Remove environmental factors such as NSAIDs and smoking
- Reduce emotional stress (in a subset of patients)
Endoscopic therapy is used to treat complications, such as bleeding, that may arise in particularly recalcitrant ulcers.
With the increased success of new acid-reducing and other pH-stabilizing drugs, there has been a decreased need to resort to surgery to treat peptic ulcer disease. The most common reason for surgical therapy in benign gastric ulcers is failure of the ulcer to completely heal after an adequate trial of medical or endoscopic therapy. Surgery is also indicated to treat major complications such as gastrointestinal hemorrhage, perforation or gastric outlet obstruction.