Gastric Ulcer

Gastric UlcerGastric Ulcer

Even though gastric ulcer is a common disease, Even though gastric ulcer is a common disease, a diagnosis can be difficult because it has a wide a diagnosis can be difficult because it has a wide spectrum of clinical presentations, ranging fromspectrum of clinical presentations, ranging from:: --asymptomatic to vague epigastric pain, asymptomatic to vague epigastric pain, nausea, and iron-deficiency anemia to nausea, and iron-deficiency anemia to

--acute life-threatening hemorrhage.acute life-threatening hemorrhage.

The normal stomach maintains a balance betweenThe normal stomach maintains a balance between:: protective factorsprotective factors - - such as mucus and bicarbonate such as mucus and bicarbonate

secretion and secretion and aggressive factorsaggressive factors - - such as acid secretion and pepsinsuch as acid secretion and pepsin

Gastric ulcers develop when aggressive factors Gastric ulcers develop when aggressive factors overcome protective mechanisms.overcome protective mechanisms.

Causes

The two major etiological factors for The two major etiological factors for ppepticeptic ulcer disease (PUD) areulcer disease (PUD) are::

Helicobacter pylori infection Helicobacter pylori infection nonsteroidal anti-inflammatory drug nonsteroidal anti-inflammatory drug

(NSAID) consumption (NSAID) consumption

70% of all gastric ulcers occurring in the United 70% of all gastric ulcers occurring in the United States can be attributed to H pylori infectionStates can be attributed to H pylori infection..

Helicobacter pyloriHelicobacter pylori tthe bacterium's spiral shape and he bacterium's spiral shape and

flagella facilitate its penetration flagella facilitate its penetration into the mucous layer and its into the mucous layer and its attachment to the epithelial layer attachment to the epithelial layer

it releases it releases phospholipasephospholipase and and proteasesproteases, which cause further , which cause further mucosal damage mucosal damage

aa cytotoxin-associated gene ( cytotoxin-associated gene (cagcag A) has been isolated in A) has been isolated in approximately 65% of the approximately 65% of the bacteriabacteria

tthe products of this gene are he products of this gene are associated with more severe associated with more severe gastritis, gastric ulcer, gastric gastritis, gastric ulcer, gastric cancer, and lymphoma cancer, and lymphoma

NSAIDNSAID 26% of gastric ulcers26% of gastric ulcers secondary to a decrease in prostaglandin secondary to a decrease in prostaglandin

production resulting from the inhibition of production resulting from the inhibition of cyclooxygenase.1cyclooxygenase.1

tthe the tyypical effects of NSAIDs are pical effects of NSAIDs are superficial superficial gastric erosionsgastric erosions and and petechial lesionspetechial lesions

tthe greatest risk of developing an ulcer occurs he greatest risk of developing an ulcer occurs during the first 3 months of NSAID use during the first 3 months of NSAID use

patients with H pylori infection may be twice patients with H pylori infection may be twice as likely to get a bleeding peptic ulcer.as likely to get a bleeding peptic ulcer.

In the In the CelecoxibCelecoxib Long-term Arthritis Safety Study Long-term Arthritis Safety Study (CLASS), they found a significantly lower (CLASS), they found a significantly lower incidence of symptomatic ulcers in patients incidence of symptomatic ulcers in patients taking celecoxib for the initial 6 months as taking celecoxib for the initial 6 months as compared to patients taking ibuprofen or compared to patients taking ibuprofen or diclofenac diclofenac

Other medicationsOther medications that predispose patients to that predispose patients to gastroduodenal ulcers include gastroduodenal ulcers include potassium chloride, potassium chloride, chemotherapeutic agents, and bisphosphonateschemotherapeutic agents, and bisphosphonates

A rare cause of PUD is A rare cause of PUD is Zollinger-Ellison syndromeZollinger-Ellison syndrome (gastrinoma(gastrinoma)). The hallmark of Zollinger-Ellison . The hallmark of Zollinger-Ellison syndrome is syndrome is :: profound hypersecretion of gastric acidprofound hypersecretion of gastric acid ssignificant disruption of the mucosal integrityignificant disruption of the mucosal integrity

Cigarette smokingCigarette smoking - p- people who smoke tend to eople who smoke tend to develop more frequent and recurrent ulcers and develop more frequent and recurrent ulcers and their ulcers are more resistant to therapy their ulcers are more resistant to therapy

Frequency United States - it is estimated to affect

0.92% of the population or 1.6 million persons.

Epidemiological studies 1970-1985, a marked decrease in the rate of duodenal ulcer occurred, while the rate of gastric ulcer remained stable. people with low socioeconomic status are

more likely to acquire H pylori infection individuals who are infected are 3 times

more likely to develop gastric ulcer compared to those unexposed to the bacteria.

simple gastric ulcer is in decline, the simple gastric ulcer is in decline, the incidence of complicated gastric ulcer and incidence of complicated gastric ulcer and hospitalization has remained stable, hospitalization has remained stable, partly due to the concomitant use of partly due to the concomitant use of aspirin in an aging population aspirin in an aging population

International Denmark, lifetime prevalence of gastric

cancer is 1.2% for men and 0.6% for women

The annual incidence of gastric ulcers Japan - 1 case per 1000 population Norway - 1.5 cases per 1000 population Scotland - 2.7 cases per 1000 population

Mortality/Morbidity tthe mortality rate is higher in patients he mortality rate is higher in patients older than older than

75 years75 years ((attributable to a high rate of attributable to a high rate of NSAID useNSAID use in this age groupin this age group))

tthe other high-risk groups he other high-risk groups -- chronicchronic renal renal insufficiencyinsufficiency and and diabetesdiabetes

Sex the male-to-female ratio is 1:1 in the United

States and 18:1 in IndiaAge

the incidence of gastric ulcer increases with age increasing NSAID use a high prevalence of H pylori infection in

persons older than 50 years

ClinicalHistoryHistory

cclassic lassic gastric ulcergastric ulcer pain is described as pain is described as pain occurring pain occurring shortly after mealsshortly after meals, for , for which antacids provide minimal reliefwhich antacids provide minimal relief

tthe pain from gastric ulcer is typically he pain from gastric ulcer is typically located in the located in the epigastriumepigastrium;; in the right in the right upper quadrant and elsewhereupper quadrant and elsewhere

dduodenal ulceruodenal ulcer pain often occurs pain often occurs hours hours after meals and at nightafter meals and at night; ; relieved with relieved with food or antacidsfood or antacids

ppain with ain with radiation to the backradiation to the back is is suggestive of a posterior penetrating suggestive of a posterior penetrating gastric ulcer complicated by pancreatitisgastric ulcer complicated by pancreatitis

ppatients with bleeding gastric ulcers may atients with bleeding gastric ulcers may give a history of give a history of hematemesishematemesis,, melena melena, or , or episodes of episodes of presyncopepresyncope

mmelena can be intermittent over several elena can be intermittent over several days or multiple episodes in a single day.days or multiple episodes in a single day.

PhysicalPhysical

eepigastric tendernesspigastric tenderness may or may not be may or may not be presentpresent

rright upper quadrant tendernessight upper quadrant tenderness may may suggest a biliary etiology or, less frequently, suggest a biliary etiology or, less frequently, PUDPUD

iin the presence of gastric outlet obstruction, n the presence of gastric outlet obstruction, abdominal distension and succussion splashabdominal distension and succussion splash may be foundmay be found

a a palpable mass shouldpalpable mass should raise the suggestion raise the suggestion of a of a gastric malignancygastric malignancy

iinvoluntary guardingnvoluntary guarding is indicative of is indicative of peritonitis secondary to gastric perforationperitonitis secondary to gastric perforation

ppatients should be checked for atients should be checked for melenamelena, , which is indicative of bleeding from a which is indicative of bleeding from a gastroduodenal ulcergastroduodenal ulcer

ddigital rectal examination can be easily igital rectal examination can be easily performed in the office to check for melena.performed in the office to check for melena.

Differential Diagnoses CholecystitisCholecystitis Crohn DiseaseCrohn Disease Duodenal UlcersDuodenal Ulcers Gastric CancerGastric Cancer Pancreatitis, ChronicPancreatitis, Chronic Zollinger-Ellison SyndromeZollinger-Ellison Syndrome Other Problems to Be ConsideredOther Problems to Be Considered

Nonulcer dyspepsia (NUD)Nonulcer dyspepsia (NUD) or functional dyspepsia or functional dyspepsia (a(a diagnosis of exclusion diagnosis of exclusion in the absence of any in the absence of any organic disease after thorough evaluation are organic disease after thorough evaluation are thought to have functional dyspepsia thought to have functional dyspepsia

Crohn diseaseCrohn disease: Crohn ulceration can involve any : Crohn ulceration can involve any part of the GI tract from the buccal mucosa to the part of the GI tract from the buccal mucosa to the rectum. Isolated Crohn ulceration of the stomach rectum. Isolated Crohn ulceration of the stomach is rare, although it may cause duodenal or ileal is rare, although it may cause duodenal or ileal ulcerations.ulcerations.

Laboratory Studies

Routine laboratory tests: complete blood cell count iron studies, can help detect anemia.

Anemia and weight loss are alarm signals and mandate early endoscopy to rule out other sources of chronic GI blood loss.

Imaging StudiesUpper GI radiographyUpper GI radiography aa double-contrast barium study double-contrast barium study --benign

gastric ulcers

Malignant gastric ulcers

Other TestsOther Tests H pylori testingH pylori testing

Invasive testsInvasive tests Biopsy Biopsy Culture Culture Rapid urease test Rapid urease test

Noninvasive testsNoninvasive tests Antibody testing Antibody testing Urea breath testing Urea breath testing Stool antigen Stool antigen

ProceduresProcedures Esophagogastroduodenoscopy (EGD)Esophagogastroduodenoscopy (EGD)

endoscopy is a relatively safe procedure in endoscopy is a relatively safe procedure in experienced handsexperienced hands

direct visualization to obtain biopsy specimens direct visualization to obtain biopsy specimens and also to perform endoscopic therapy for and also to perform endoscopic therapy for bleeding ulcersbleeding ulcers

the preferred modality for the diagnosis of the preferred modality for the diagnosis of gastric ulcer and gastric cancergastric ulcer and gastric cancer

a repeat endoscopy after 6 weeks of therapy is a repeat endoscopy after 6 weeks of therapy is recommended to confirm healing of a gastric recommended to confirm healing of a gastric ulcer and to help definitively rule out gastric ulcer and to help definitively rule out gastric malignancymalignancy

upper endoscopy with biopsy is upper endoscopy with biopsy is the most the most sensitive and specific methodsensitive and specific method for diagnosing for diagnosing gastric and esophageal cancergastric and esophageal cancer

7 biopsy samples obtained from the base and 7 biopsy samples obtained from the base and ulcer margins increase the ulcer margins increase the sensitivity to 99% sensitivity to 99%

BBenign ulcersenign ulcers

MMalignant ulcersalignant ulcers

Treatment

H pylori eradicationH pylori eradication Bismuth, metronidazole, and tetracycline Bismuth, metronidazole, and tetracycline

qid with H2 blockers bidqid with H2 blockers bid Bismuth, metronidazole, and tetracycline Bismuth, metronidazole, and tetracycline

bid with a PPI (Helidac)bid with a PPI (Helidac) Prevacid, amoxicillin, and clarithromycin Prevacid, amoxicillin, and clarithromycin

bid (PrevPac)bid (PrevPac) Prilosec, metronidazole, and Prilosec, metronidazole, and

clarithromycin bidclarithromycin bid Ranitidine, bismuth, and clarithromycin Ranitidine, bismuth, and clarithromycin

with amoxicillin, metronidazole, or with amoxicillin, metronidazole, or tetracycline bidtetracycline bid

Endoscopic therapyEndoscopic therapy Surgical CareSurgical Care ConsultationsConsultations DietDiet

Medication Proton pump inhibitorsProton pump inhibitors

Omeprazole (Prilosec) - 40 mg PO Lansoprazole (Prevacid) - 15-30 mg PO Rabeprazole (Aciphex) - 20 mRabeprazole (Aciphex) - 20 mgg tab PO tab PO Pantoprazole (Protonix) - 40 mg PO Pantoprazole (Protonix) - 40 mg PO Esomeprazole (Nexium) - 40 mg PO Esomeprazole (Nexium) - 40 mg PO

Histamine H2 antagonistsHistamine H2 antagonists Nizatidine (Axid) - 75 mg PO Nizatidine (Axid) - 75 mg PO Ranitidine (Zantac) - 150 mg PO Ranitidine (Zantac) - 150 mg PO

Helicobacter pylori eradication agentsHelicobacter pylori eradication agents Clarithromycin (Biaxin) - 250-500 mg PO Metronidazole (Flagyl) - 250 mg PO Bismuth subsalicylate (Pepto-Bismol) - 2

tab or 30 mL PO Tetracycline (Sumycin) - 250 mg PO Amoxicillin (Trimox) - 500 mg PO Amoxicillin (Trimox) - 500 mg PO

Gastrointestinal agentsGastrointestinal agents Sucralfate (Carafate) - 1 g PO

Complications hemorrhagehemorrhage perforationperforation gastric outlet obstructiongastric outlet obstruction gastric malignancygastric malignancy

the risk is approximately 2% in the initial 3 the risk is approximately 2% in the initial 3 years years

H pylori infection is associated with gastric H pylori infection is associated with gastric lymphoma or mucosa-associated lymphoid lymphoma or mucosa-associated lymphoid tissue (MALT) lymphoma tissue (MALT) lymphoma

malignancy should be strongly considered in the malignancy should be strongly considered in the case of a persistent nonhealing gastric ulcer case of a persistent nonhealing gastric ulcer

Patient Education Instruct patients to avoid NSAIDs.Instruct patients to avoid NSAIDs. Discourage alcohol consumption and Discourage alcohol consumption and

cigarette smoking because these cigarette smoking because these activities impair gastric mucosal activities impair gastric mucosal protection.protection.