Peptic Ulcer DiseasePeptic Ulcer Disease

Peptic Ulcer DiseasePeptic Ulcer Disease

Condition characterized by Condition characterized by Erosion of GI mucosa resulting from Erosion of GI mucosa resulting from

digestive action of HCl and pepsin digestive action of HCl and pepsin

Peptic Ulcer DiseasePeptic Ulcer Disease

Ulcer developmentUlcer developmentLower esophagusLower esophagusStomachStomachDuodenumDuodenum10% of men, 4% of women10% of men, 4% of women

TypesTypes

Acute Acute Superficial erosionSuperficial erosionMinimal erosionMinimal erosion

ChronicChronicMuscular wall erosion with formation Muscular wall erosion with formation

of fibrous tissue of fibrous tissue Present continuously for many months Present continuously for many months

or intermittentlyor intermittently

Peptic Ulcer Disease Etiology and Pathophysiology

Peptic Ulcer Disease Etiology and Pathophysiology

Develop only in presence of acid Develop only in presence of acid environmentenvironment

Excess of gastric acid not necessary for Excess of gastric acid not necessary for ulcer developmentulcer development

Person with a gastric ulcer has normal to Person with a gastric ulcer has normal to less than normal gastric acidity less than normal gastric acidity compared with person with a duodenal compared with person with a duodenal ulcerulcer

Peptic Ulcer Disease Etiology and Pathophysiology

Peptic Ulcer Disease Etiology and Pathophysiology

Some intraluminal acid does seem to be Some intraluminal acid does seem to be essential for a gastric ulcer to occuressential for a gastric ulcer to occur

Pepsinogen is activated to pepsin in Pepsinogen is activated to pepsin in presence of HCl and a pH of 2 to 3presence of HCl and a pH of 2 to 3

Secretion of HCl by parietal cells has a Secretion of HCl by parietal cells has a pH of 0.8pH of 0.8

pH reaches 2 to 3 after mixing with pH reaches 2 to 3 after mixing with stomach contentsstomach contents

Peptic Ulcer Disease Etiology and Pathophysiology

Peptic Ulcer Disease Etiology and Pathophysiology

At pH level 3.5 or more, stomach acid is At pH level 3.5 or more, stomach acid is neutralizedneutralizedPepsin has little or no proteolytic Pepsin has little or no proteolytic

activityactivity Surface mucosa of stomach is renewed Surface mucosa of stomach is renewed

about every 3 daysabout every 3 days Mucosa can continually repair itself Mucosa can continually repair itself

except in extreme instancesexcept in extreme instances

Peptic Ulcer Disease Etiology and Pathophysiology

Peptic Ulcer Disease Etiology and Pathophysiology

Mucosal barrier prevents back diffusion Mucosal barrier prevents back diffusion of acid from gastric lumen through of acid from gastric lumen through mucosal layers to underlying tissuemucosal layers to underlying tissue

Mucosal barrier can be impaired and Mucosal barrier can be impaired and back diffusion can occurback diffusion can occur

Back-Diffusion of Acids Back-Diffusion of Acids

Fig. 40-13

Peptic Ulcer Disease Etiology and Pathophysiology

Peptic Ulcer Disease Etiology and Pathophysiology

HCl freely enters mucosa when barrier is HCl freely enters mucosa when barrier is brokenbrokenInjury to tissue occursInjury to tissue occursResult: cellular destruction and Result: cellular destruction and

inflammationinflammation

Peptic Ulcer Disease Etiology and Pathophysiology

Peptic Ulcer Disease Etiology and Pathophysiology

Histamine is released Histamine is released Vasodilation, Vasodilation, ↑ capillary permeability ↑ capillary permeability Further secretion of acid and pepsinFurther secretion of acid and pepsin

Peptic Ulcer Disease Etiology and Pathophysiology

Peptic Ulcer Disease Etiology and Pathophysiology

Ulcerogenic drugs inhibit synthesis of Ulcerogenic drugs inhibit synthesis of prostaglandins and cause abnormal prostaglandins and cause abnormal permeability permeability

Corticosteroids Corticosteroids ↓ rate of mucosal cell ↓ rate of mucosal cell renewal thereby ↓ protective effectsrenewal thereby ↓ protective effects

Peptic Ulcer Disease Etiology and Pathophysiology

Peptic Ulcer Disease Etiology and Pathophysiology

When mucosal barrier is disrupted, there When mucosal barrier is disrupted, there is a compensatory is a compensatory ↑ in blood flow↑ in blood flowProstaglandin-like substances, Prostaglandin-like substances,

histamines act as vasodilators histamines act as vasodilators Hydrogen ions are rapidly removed Hydrogen ions are rapidly removed Buffers are delivered Buffers are delivered Nutrients arriveNutrients arrive↑ ↑ Mucosal cell replication Mucosal cell replication

Disruption of Gastric Mucosal BarrierDisruption of Gastric Mucosal Barrier

Fig. 40-14

Peptic Ulcer Disease Etiology and Pathophysiology

Peptic Ulcer Disease Etiology and Pathophysiology

When blood flow is not sufficient, tissue When blood flow is not sufficient, tissue injury resultsinjury results

Peptic Ulcer Disease Etiology and Pathophysiology

Peptic Ulcer Disease Etiology and Pathophysiology

Two mechanisms that protectTwo mechanisms that protectMucus forms a layer that entraps or Mucus forms a layer that entraps or

slows diffusion of hydrogen ions across slows diffusion of hydrogen ions across mucosal barrier mucosal barrier

Bicarbonate is secretedBicarbonate is secreted Neutralizes HCl acid in lumen of GI tractNeutralizes HCl acid in lumen of GI tract

Peptic Ulcer Disease Etiology and Pathophysiology

Peptic Ulcer Disease Etiology and Pathophysiology

↑ ↑ Vagal nerve stimulation results in Vagal nerve stimulation results in hypersecretion of HCl acidhypersecretion of HCl acid↑ ↑ HCl acid can alter mucosal barrierHCl acid can alter mucosal barrierDuodenal ulcers are associated with ↑ Duodenal ulcers are associated with ↑

acidacid

Gastric UlcersGastric Ulcers

Commonly found on lesser curvature in Commonly found on lesser curvature in close proximity to antral junctionclose proximity to antral junctionLess common than duodenal ulcersLess common than duodenal ulcersPrevalent in women, older adults, Prevalent in women, older adults,

persons from lower socioeconomic persons from lower socioeconomic classclass

Gastric UlcersGastric Ulcers

Characterized by Characterized by A normal to low secretion of gastric A normal to low secretion of gastric

acidacidBack diffusion of acid is greater Back diffusion of acid is greater

(chronic)(chronic)

Gastric UlcersGastric Ulcers

Critical pathologic process is amount of Critical pathologic process is amount of acid able to penetrate mucosal barrier acid able to penetrate mucosal barrier

H. pyloriH. pylori is present in 50% to 70% is present in 50% to 70%

Gastric UlcersGastric Ulcers

H. pyloriH. pylori is thought to be more is thought to be more destructive when noxious agents are destructive when noxious agents are used, or patient smokesused, or patient smokes

Gastric UlcersGastric Ulcers

Drugs can cause acute gastric ulcersDrugs can cause acute gastric ulcersAspirin, corticosteroids, NSAIDs, Aspirin, corticosteroids, NSAIDs,

reserpine reserpine Or known causative factorsOr known causative factors

Chronic alcohol abuse, chronic gastritisChronic alcohol abuse, chronic gastritis

Duodenal UlcersDuodenal Ulcers

Occur at any age and in anyoneOccur at any age and in anyone↑ ↑ Between ages of 35 to 45 years Between ages of 35 to 45 years

Account for ~80% of all peptic ulcersAccount for ~80% of all peptic ulcers

Duodenal UlcersDuodenal Ulcers

Associated with ↑ HCl acid secretionAssociated with ↑ HCl acid secretion

H. pyloriH. pylori is found in 90-95% of patients is found in 90-95% of patientsDirect relationship has not been foundDirect relationship has not been found

Duodenal UlcersDuodenal Ulcers

Diseases with ↑ risk of duodenal ulcersDiseases with ↑ risk of duodenal ulcersCOPD, cirrhosis of liver, chronic COPD, cirrhosis of liver, chronic

pancreatitis, hyperparathyroidism, pancreatitis, hyperparathyroidism, chronic renal failurechronic renal failure

Treatments used for these conditions Treatments used for these conditions may promote ulcer developmentmay promote ulcer development

Psychological Stress UlcersPsychological Stress Ulcers

Acute ulcers that develop following a Acute ulcers that develop following a major physiologic insult such as trauma major physiologic insult such as trauma or surgery or surgery

A form of erosive gastritis A form of erosive gastritis

Psychological Stress UlcersPsychological Stress Ulcers

Gastric mucosa of body of stomach Gastric mucosa of body of stomach undergoes a period of transient ischemia undergoes a period of transient ischemia in association within association withHypotensionHypotensionSevere injurySevere injuryExtensive burnsExtensive burnsComplicated surgery Complicated surgery

Psychological Stress UlcersPsychological Stress Ulcers

Ischemia due to ↓ capillary blood flow or Ischemia due to ↓ capillary blood flow or shunting of blood away from GI tract so shunting of blood away from GI tract so that blood flow bypasses gastric mucosathat blood flow bypasses gastric mucosaImbalance between destructive Imbalance between destructive

properties of HCl acid and pepsin, and properties of HCl acid and pepsin, and protective factors of stomach’s protective factors of stomach’s mucosal barriermucosal barrier

Peptic Ulcer DiseaseClinical Manifestations Peptic Ulcer DiseaseClinical Manifestations Common to have no pain or other Common to have no pain or other

symptomssymptomsGastric and duodenal mucosa not rich Gastric and duodenal mucosa not rich

in sensory pain fibers in sensory pain fibers Duodenal ulcer painDuodenal ulcer pain

Burning, cramplikeBurning, cramplikeGastric ulcer pain Gastric ulcer pain

Burning, gaseous Burning, gaseous

Peptic Ulcer DiseaseComplications Peptic Ulcer DiseaseComplications

3 major complications3 major complicationsHemorrhageHemorrhagePerforationPerforationGastric outlet obstruction Gastric outlet obstruction

Initially treated conservativelyInitially treated conservatively May require surgery at any time during May require surgery at any time during

course of therapy course of therapy

Peptic Ulcer DiseaseHemorrhage Peptic Ulcer DiseaseHemorrhage

Most common complication of peptic Most common complication of peptic ulcer disease ulcer disease

Develops from erosion of Develops from erosion of Granulation tissue found at base of Granulation tissue found at base of

ulcer during healingulcer during healingUlcer through a major blood vesselUlcer through a major blood vessel

Peptic Ulcer DiseasePerforation Peptic Ulcer DiseasePerforation Most lethal complication of peptic ulcerMost lethal complication of peptic ulcer

Commonly seen in large penetrating Commonly seen in large penetrating duodenal ulcers that have not healed and duodenal ulcers that have not healed and are located on posterior mucosal wallare located on posterior mucosal wall

Peptic Ulcer DiseasePerforation Peptic Ulcer DiseasePerforation Perforated gastric ulcers often located on Perforated gastric ulcers often located on

lesser curvature of stomach lesser curvature of stomach

Peptic Ulcer DiseasePerforation

Peptic Ulcer DiseasePerforation

Fig. 40-15

Peptic Ulcer DiseasePerforation Peptic Ulcer DiseasePerforation Occurs when ulcer penetrates serosal Occurs when ulcer penetrates serosal

surfacesurfaceSpillage of their gastric or duodenal Spillage of their gastric or duodenal

contents into peritoneal cavitycontents into peritoneal cavity Size of perforation directly proportional Size of perforation directly proportional

to length of time patient has had ulcerto length of time patient has had ulcer Sudden, dramatic onsetSudden, dramatic onset

Peptic Ulcer DiseaseGastric Outlet ObstructionPeptic Ulcer DiseaseGastric Outlet Obstruction

Ulcers located in antrum and prepyloric Ulcers located in antrum and prepyloric and pyloric areas of stomach and pyloric areas of stomach

Duodenum can predispose to gastric Duodenum can predispose to gastric outlet obstructionoutlet obstruction

↑ ↑ contractile force needed to empty contractile force needed to empty stomach results in hypertrophy stomach results in hypertrophy of of stomach wallstomach wall

Peptic Ulcer DiseaseGastric Outlet ObstructionPeptic Ulcer DiseaseGastric Outlet Obstruction

After longstanding obstruction stomach After longstanding obstruction stomach enters decompensated phase enters decompensated phase

Results in dilation and atonyResults in dilation and atony

Peptic Ulcer DiseaseGastric Outlet ObstructionPeptic Ulcer DiseaseGastric Outlet Obstruction

Obstruction is not totally due to fibrous Obstruction is not totally due to fibrous scar tissue scar tissue Active ulcer formation is associated Active ulcer formation is associated

with edema, inflammation, with edema, inflammation, pylorospasm pylorospasm

All contribute to narrowing of pylorus All contribute to narrowing of pylorus

Peptic Ulcer DiseaseGastric Outlet ObstructionPeptic Ulcer DiseaseGastric Outlet Obstruction

Usually has a history of ulcer pain Usually has a history of ulcer pain

Short duration or absence of pain Short duration or absence of pain indicative of a malignant obstructionindicative of a malignant obstruction

Peptic Ulcer DiseaseGastric Outlet ObstructionPeptic Ulcer DiseaseGastric Outlet Obstruction

Vomiting is commonVomiting is common

Constipation is a common complaint Constipation is a common complaint Dehydration, lack of roughage in diet Dehydration, lack of roughage in diet

May show swelling in upper abdomen May show swelling in upper abdomen

Peptic Ulcer DiseaseDiagnostic Studies Peptic Ulcer DiseaseDiagnostic Studies

Endoscopy procedure most often usedEndoscopy procedure most often usedDetermines degree of ulcer healing Determines degree of ulcer healing

after treatmentafter treatmentTissue specimens can be obtained to Tissue specimens can be obtained to

identify identify H. pyloriH. pylori and to rule out and to rule out gastric cancergastric cancer

Peptic Ulcer DiseaseDiagnostic Studies Peptic Ulcer DiseaseDiagnostic Studies

Tests for Tests for H. pyloriH. pyloriNoninvasive testsNoninvasive tests

Serum or whole blood antibody testsSerum or whole blood antibody tests Immunoglobin G (IgG)Immunoglobin G (IgG)

Urea breath testUrea breath testInvasive testsInvasive tests

Biopsy of stomach Biopsy of stomach Rapid urease test Rapid urease test

Peptic Ulcer DiseaseDiagnostic Studies Peptic Ulcer DiseaseDiagnostic Studies

Barium contrast studiesBarium contrast studiesWidely usedWidely used

X-ray studiesX-ray studiesIneffective in differentiating a peptic Ineffective in differentiating a peptic

ulcer from a malignant tumorulcer from a malignant tumor

Peptic Ulcer DiseaseDiagnostic Studies Peptic Ulcer DiseaseDiagnostic Studies

Gastric analysisGastric analysisIdentifying a possible gastrinomaIdentifying a possible gastrinomaDetermining degree of gastric Determining degree of gastric

hyperacidityhyperacidityEvaluating results of therapy Evaluating results of therapy

Peptic Ulcer DiseaseDiagnostic Studies Peptic Ulcer DiseaseDiagnostic Studies

Laboratory analysisLaboratory analysisCBCCBCUrinalysisUrinalysisLiver enzyme studiesLiver enzyme studiesSerum amylase determinationSerum amylase determinationStool examination Stool examination