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Peptic Ulcer Disease. Peptic Ulcer Disease. Condition characterized by Erosion of GI mucosa resulting from digestive action of HCl and pepsin. Peptic Ulcer Disease. Ulcer development Lower esophagus Stomach Duodenum 10% of men, 4% of women. Types. Acute Superficial erosion

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peptic ulcer disease1
Peptic Ulcer Disease
  • Condition characterized by
    • Erosion of GI mucosa resulting from digestive action of HCl and pepsin
peptic ulcer disease2
Peptic Ulcer Disease
  • Ulcer development
    • Lower esophagus
    • Stomach
    • Duodenum
    • 10% of men, 4% of women
types
Types
  • Acute
    • Superficial erosion
    • Minimal erosion
  • Chronic
    • Muscular wall erosion with formation of fibrous tissue
    • Present continuously for many months or intermittently
peptic ulcer disease etiology and pathophysiology
Peptic Ulcer Disease Etiology and Pathophysiology
  • Develop only in presence of acid environment
  • Excess of gastric acid not necessary for ulcer development
  • Person with a gastric ulcer has normal to less than normal gastric acidity compared with person with a duodenal ulcer
peptic ulcer disease etiology and pathophysiology1
Peptic Ulcer Disease Etiology and Pathophysiology
  • Some intraluminal acid does seem to be essential for a gastric ulcer to occur
  • Pepsinogen is activated to pepsin in presence of HCl and a pH of 2 to 3
  • Secretion of HCl by parietal cells has a pH of 0.8
  • pH reaches 2 to 3 after mixing with stomach contents
peptic ulcer disease etiology and pathophysiology2
Peptic Ulcer Disease Etiology and Pathophysiology
  • At pH level 3.5 or more, stomach acid is neutralized
    • Pepsin has little or no proteolytic activity
  • Surface mucosa of stomach is renewed about every 3 days
  • Mucosa can continually repair itself except in extreme instances
peptic ulcer disease etiology and pathophysiology3
Peptic Ulcer Disease Etiology and Pathophysiology
  • Mucosal barrier prevents back diffusion of acid from gastric lumen through mucosal layers to underlying tissue
  • Mucosal barrier can be impaired and back diffusion can occur
peptic ulcer disease etiology and pathophysiology4
Peptic Ulcer Disease Etiology and Pathophysiology
  • HCl freely enters mucosa when barrier is broken
    • Injury to tissue occurs
    • Result: cellular destruction and inflammation
peptic ulcer disease etiology and pathophysiology5
Peptic Ulcer Disease Etiology and Pathophysiology
  • Histamine is released
    • Vasodilation, ↑ capillary permeability
    • Further secretion of acid and pepsin
peptic ulcer disease etiology and pathophysiology6
Peptic Ulcer Disease Etiology and Pathophysiology
  • Ulcerogenic drugs inhibit synthesis of prostaglandins and cause abnormal permeability
  • Corticosteroids ↓ rate of mucosal cell renewal thereby ↓ protective effects
peptic ulcer disease etiology and pathophysiology7
Peptic Ulcer Disease Etiology and Pathophysiology
  • When mucosal barrier is disrupted, there is a compensatory ↑ in blood flow
    • Prostaglandin-like substances, histamines act as vasodilators
    • Hydrogen ions are rapidly removed
    • Buffers are delivered
    • Nutrients arrive
    • ↑ Mucosal cell replication
peptic ulcer disease etiology and pathophysiology8
Peptic Ulcer Disease Etiology and Pathophysiology
  • When blood flow is not sufficient, tissue injury results
peptic ulcer disease etiology and pathophysiology9
Peptic Ulcer Disease Etiology and Pathophysiology
  • Two mechanisms that protect
    • Mucus forms a layer that entraps or slows diffusion of hydrogen ions across mucosal barrier
    • Bicarbonate is secreted
      • Neutralizes HCl acid in lumen of GI tract
peptic ulcer disease etiology and pathophysiology10
Peptic Ulcer Disease Etiology and Pathophysiology
  • ↑ Vagal nerve stimulation results in hypersecretion of HCl acid
    • ↑ HCl acid can alter mucosal barrier
    • Duodenal ulcers are associated with ↑ acid
gastric ulcers
Gastric Ulcers
  • Commonly found on lesser curvature in close proximity to antral junction
    • Less common than duodenal ulcers
    • Prevalent in women, older adults, persons from lower socioeconomic class
gastric ulcers1
Gastric Ulcers
  • Characterized by
    • A normal to low secretion of gastric acid
    • Back diffusion of acid is greater (chronic)
gastric ulcers2
Gastric Ulcers
  • Critical pathologic process is amount of acid able to penetrate mucosal barrier
  • H. pylori is present in 50% to 70%
gastric ulcers3
Gastric Ulcers
  • H. pylori is thought to be more destructive when noxious agents are used, or patient smokes
gastric ulcers4
Gastric Ulcers
  • Drugs can cause acute gastric ulcers
    • Aspirin, corticosteroids, NSAIDs, reserpine
    • Or known causative factors
      • Chronic alcohol abuse, chronic gastritis
duodenal ulcers
Duodenal Ulcers
  • Occur at any age and in anyone
    • ↑ Between ages of 35 to 45 years
  • Account for ~80% of all peptic ulcers
duodenal ulcers1
Duodenal Ulcers
  • Associated with ↑ HCl acid secretion
  • H. pylori is found in 90-95% of patients
    • Direct relationship has not been found
duodenal ulcers2
Duodenal Ulcers
  • Diseases with ↑ risk of duodenal ulcers
    • COPD, cirrhosis of liver, chronic pancreatitis, hyperparathyroidism, chronic renal failure
  • Treatments used for these conditions may promote ulcer development
psychological stress ulcers
Psychological Stress Ulcers
  • Acute ulcers that develop following a major physiologic insult such as trauma or surgery
  • A form of erosive gastritis
psychological stress ulcers1
Psychological Stress Ulcers
  • Gastric mucosa of body of stomach undergoes a period of transient ischemia in association with
    • Hypotension
    • Severe injury
    • Extensive burns
    • Complicated surgery
psychological stress ulcers2
Psychological Stress Ulcers
  • Ischemia due to ↓ capillary blood flow or shunting of blood away from GI tract so that blood flow bypasses gastric mucosa
    • Imbalance between destructive properties of HCl acid and pepsin, and protective factors of stomach’s mucosal barrier
peptic ulcer disease clinical manifestations
Peptic Ulcer DiseaseClinical Manifestations
  • Common to have no pain or other symptoms
    • Gastric and duodenal mucosa not rich in sensory pain fibers
    • Duodenal ulcer pain
      • Burning, cramplike
    • Gastric ulcer pain
      • Burning, gaseous
peptic ulcer disease complications
Peptic Ulcer DiseaseComplications
  • 3 major complications
    • Hemorrhage
    • Perforation
    • Gastric outlet obstruction
  • Initially treated conservatively
  • May require surgery at any time during course of therapy
peptic ulcer disease hemorrhage
Peptic Ulcer DiseaseHemorrhage
  • Most common complication of peptic ulcer disease
  • Develops from erosion of
    • Granulation tissue found at base of ulcer during healing
    • Ulcer through a major blood vessel
peptic ulcer disease perforation
Peptic Ulcer DiseasePerforation
  • Most lethal complication of peptic ulcer
  • Commonly seen in large penetrating duodenal ulcers that have not healed and are located on posterior mucosal wall
peptic ulcer disease perforation1
Peptic Ulcer DiseasePerforation
  • Perforated gastric ulcers often located on lesser curvature of stomach
peptic ulcer disease perforation3
Peptic Ulcer DiseasePerforation
  • Occurs when ulcer penetrates serosal surface
    • Spillage of their gastric or duodenal contents into peritoneal cavity
  • Size of perforation directly proportional to length of time patient has had ulcer
  • Sudden, dramatic onset
peptic ulcer disease gastric outlet obstruction
Peptic Ulcer DiseaseGastric Outlet Obstruction
  • Ulcers located in antrum and prepyloric and pyloric areas of stomach
  • Duodenum can predispose to gastric outlet obstruction
  • ↑ contractile force needed to empty stomach results in hypertrophy of stomach wall
peptic ulcer disease gastric outlet obstruction1
Peptic Ulcer DiseaseGastric Outlet Obstruction
  • After longstanding obstruction stomach enters decompensated phase
  • Results in dilation and atony
peptic ulcer disease gastric outlet obstruction2
Peptic Ulcer DiseaseGastric Outlet Obstruction
  • Obstruction is not totally due to fibrous scar tissue
    • Active ulcer formation is associated with edema, inflammation, pylorospasm
    • All contribute to narrowing of pylorus
peptic ulcer disease gastric outlet obstruction3
Peptic Ulcer DiseaseGastric Outlet Obstruction
  • Usually has a history of ulcer pain
  • Short duration or absence of pain indicative of a malignant obstruction
peptic ulcer disease gastric outlet obstruction4
Peptic Ulcer DiseaseGastric Outlet Obstruction
  • Vomiting is common
  • Constipation is a common complaint
    • Dehydration, lack of roughage in diet
  • May show swelling in upper abdomen
peptic ulcer disease diagnostic studies
Peptic Ulcer DiseaseDiagnostic Studies
  • Endoscopy procedure most often used
    • Determines degree of ulcer healing after treatment
    • Tissue specimens can be obtained to identify H. pylori and to rule out gastric cancer
peptic ulcer disease diagnostic studies1
Peptic Ulcer DiseaseDiagnostic Studies
  • Tests for H. pylori
    • Noninvasive tests
      • Serum or whole blood antibody tests
        • Immunoglobin G (IgG)
      • Urea breath test
    • Invasive tests
      • Biopsy of stomach
      • Rapid urease test
peptic ulcer disease diagnostic studies2
Peptic Ulcer DiseaseDiagnostic Studies
  • Barium contrast studies
    • Widely used
  • X-ray studies
    • Ineffective in differentiating a peptic ulcer from a malignant tumor
peptic ulcer disease diagnostic studies3
Peptic Ulcer DiseaseDiagnostic Studies
  • Gastric analysis
    • Identifying a possible gastrinoma
    • Determining degree of gastric hyperacidity
    • Evaluating results of therapy
peptic ulcer disease diagnostic studies4
Peptic Ulcer DiseaseDiagnostic Studies
  • Laboratory analysis
    • CBC
    • Urinalysis
    • Liver enzyme studies
    • Serum amylase determination
    • Stool examination