A peptic ulcer, also known as peptic ulcer disease (PUD), is the most common ulcerof an area of the gastrointestinal

tract that is usually acidic and thus extremely painful. It is defined as mucosal erosions equal to or greater than 0.5 cm. As many as 7090% of such ulcers are associated with Helicobacter pylori, a rod-shaped bacterium that lives in the acidic environment of the stomach; however, only 40% of those cases go to a doctor. Ulcers can also be caused or worsened by drugs such [2] as aspirin, ibuprofen, and otherNSAIDs. Four times as many peptic ulcers arise in the duodenumthe first part of the small intestine, just after the stomachas in the stomach itself. About 4% of gastric ulcers are caused by a malignant tumor, so multiple biopsies are needed to exclude cancer. Duodenal ulcers are generally benign.

[1]

Classification
By Region/Location Duodenum (called duodenal ulcer) Esophagus (called esophageal ulcer) Stomach (called gastric ulcer) Meckel's diverticulum (called Meckel's diverticulum ulcer; is very tender with palpation)

Modified Johnson Classification of peptic ulcers: Type I: Ulcer along the body of the stomach, most often along the lesser curve at incisura angularis along the locus minoris resistantiae. Type II: Ulcer in the body in combination with duodenal ulcers. Associated with acid oversecretion. Type III: In the pyloric channel within 3 cm of pylorus. Associated with acid oversecretion. Type IV: Proximal gastroesophageal ulcer Type V: Can occur throughout the stomach. Associated with chronic NSAID use (such as aspirin).

[edit]Signs

and symptoms

Symptoms of a peptic ulcer can be abdominal pain, classically epigastric strongly correlated to mealtimes. In case of duodenal ulcers the pain appears about three hours after taking a meal; bloating and abdominal fullness; waterbrash (rush of saliva after an episode of regurgitation to dilute the acid in esophagus - although this is more associated withgastroesophageal reflux disease); nausea, and copious vomiting; loss of appetite and weight loss; hematemesis (vomiting of blood); this can occur due to bleeding directly from a gastric ulcer, or from damage to the esophagus from severe/continuing vomiting. melena (tarry, foul-smelling feces due to oxidized iron from hemoglobin); rarely, an ulcer can lead to a gastric or duodenal perforation, which leads to acute peritonitis. This is extremely painful and requires immediate surgery.

A history of heartburn, gastroesophageal reflux disease (GERD) and use of certain forms of medication can raise the suspicion for peptic ulcer. Medicines associated with peptic ulcer include NSAID (nonsteroid anti-inflammatory drugs) that inhibit cyclooxygenase, and most glucocorticoids (e.g. dexamethasone and prednisolone). In patients over 45 with more than two weeks of the above symptoms, the odds for peptic ulceration are high enough to warrant rapid investigation by esophagogastroduodenoscopy. The timing of the symptoms in relation to the meal may differentiate between gastric and duodenal ulcers: A gastric ulcer would giveepigastric pain during the meal, as gastric acid production is increased as food enters the stomach. Symptoms of duodenal ulcers would initially be relieved by a meal, as the pyloric sphincter closes to concentrate the stomach contents, therefore acid is not reaching the duodenum. Duodenal ulcer pain would manifest mostly 23 hours after the meal, when the stomach begins to release digested food and acid into the duodenum. Also, the symptoms of peptic ulcers may vary with the location of the ulcer and the patient's age. Furthermore, typical ulcers tend to heal and recur and as a result the pain may occur for few days and [3] weeks and then wane or disappear. Usually, children and theelderly do not develop any symptoms unless complications have arisen. Burning or gnawing feeling in the stomach area lasting between 30 minutes and 3 hours commonly accompanies ulcers. This pain can be misinterpreted as hunger, indigestion or heartburn. Pain is usually caused by the ulcer but it may be aggravated by the stomach acidwhen it comes into contact with the ulcerated area. The pain caused by peptic ulcers can be felt anywhere from the navel up to thesternum, it may last from few minutes to several hours and it may be worse when the stomach is empty. Also, sometimes the pain may flare at night and it can commonly be temporarily relieved by eating foods that [4] buffer stomach acid or by taking anti-acid medication. However, peptic ulcer disease symptoms may be [5] different for every sufferer. [edit]Complications Gastrointestinal bleeding is the most common complication. Sudden large bleeding can be life[6] threatening. It occurs when the ulcer erodes one of the blood vessels, such as the gastroduodenal artery. Perforation (a hole in the wall) often leads to catastrophic consequences. Erosion of the gastrointestinal wall by the ulcer leads to spillage of stomach or intestinal content into the abdominal cavity. Perforation at the anterior surface of the stomach leads to acuteperitonitis, initially chemical and later bacterial peritonitis. The first sign is often sudden intense abdominal pain. Posterior wall perforation leads to bleeding due to involvement of gastroduodenal artery that lies posterior to the 1st part of duodenum. perforation and Penetration are when the ulcer continues into adjacent organs such as the liver [3] and pancreas. Gastric outlet obstruction is the narrowing of pyloric canal by scarring and swelling of gastric antrum and doudenum due to peptic ulcers. Patient often presents with severe vomiting without bile. Cancer is included in the differential diagnosis (elucidated by biopsy), Helicobacter pylori as the [3] etiological factor making it 3 to 6 times more likely to develop stomach cancer from the ulcer.

[edit]Cause

A major causative factor (60% of gastric and up to 90% of duodenal ulcers) is chronic inflammation due [7] to Helicobacter pylori thatcolonizes the antral mucosa. The immune system is unable to clear the infection, despite the appearance of antibodies. Thus, thebacterium can cause a chronic active gastritis (type B gastritis), resulting in a defect in the regulation of gastrin production by that part of the stomach, and gastrin secretion can either be increased, or as in most cases, decreased, resulting in hypo- or achlorhydria.Gastrin stimulates the production of gastric acid by parietal cells. In H. pylori colonization responses to increased gastrin, the increase in acid can contribute to the erosion of the mucosa and therefore ulcer formation. Studies in the varying occurrence of ulcers in third world countries despite high H. pylori colonization rates suggest dietary factors play a role in the pathogenesis [8] of the disease. Another major cause is the use of NSAIDs. The gastric mucosa protects itself from gastric acid with a layer of mucus, the secretion of which is stimulated by certain prostaglandins. NSAIDs block the function of cyclooxygenase 1 (cox-1), which is essential for the production of these prostaglandins. COX-2 selective anti-inflammatories (such as celecoxib or the since withdrawn rofecoxib) preferentially inhibit cox-2, which is less essential in the gastric mucosa, and roughly halve the risk of NSAID-related gastric ulceration. The incidence of duodenal ulcers has dropped significantly during the last 30 years, while the incidence of gastric ulcers has shown a small increase, mainly caused by the widespread use of NSAIDs. The drop in incidence is considered to be a cohort-phenomenon independent of the progress in treatment of the disease. The cohort-phenomenon is probably explained by improved standards of living which has [9] lowered the incidence of H. pylori infections. Although some studies have found correlations between smoking and ulcer formation, others have been more specific in exploring the risks involved and have found that smoking by itself may not be much [11][12][13][nb 1] of a risk factor unless associated with H. pyloriinfection. Some suggested risk factors such as diet, and spice consumption, were hypothesized as ulcerogens (helping cause ulcers) until late in the 20th century, but have been shown to be of relatively minor importance in the development of peptic [14] ulcers. Caffeine and coffee, also commonly thought to cause or exacerbate ulcers, have not been [15][16] found to affect ulcers to any significant extent. Similarly, while studies have found that alcohol consumption increases risk when associated with H. pyloriinfection, it does not seem to independently increase risk, and even when coupled with H. pylori infection, the increase is modest in comparison to the [11][17][nb 2] primary risk factor. Gastrinomas (Zollinger Ellison syndrome), rare gastrin-secreting tumors, also cause multiple and difficultto-heal ulcers. [edit]Diagnosis
[10]

Endoscopic image of gastric ulcer, biopsy proven to be gastric cancer.

The diagnosis is mainly established based on the characteristic symptoms. Stomach pain is usually the first signal of a peptic ulcer. In some cases, doctors may treat ulcers without diagnosing them with specific tests and observe whether the symptoms resolve, thus indicating that their primary diagnosis was accurate. Confirmation of the diagnosis is made with the help of tests such as endoscopies or barium contrast xrays. The tests are typically ordered if the symptoms do not resolve after a few weeks of treatment, or when they first appear in a person who is over age 45 or who has other symptoms such as weight loss, because stomach cancer can cause similar symptoms. Also, when severe ulcers resist treatment, particularly if a person has several ulcers or the ulcers are in unusual places, a doctor may suspect an [3] underlying condition that causes the stomach to overproduce acid. An esophagogastroduodenoscopy (EGD), a form of endoscopy, also known as agastroscopy, is carried out on patients in whom a peptic ulcer is suspected. By direct visual identification, the location and severity of an ulcer can be described. Moreover, if no ulcer is present, EGD can often provide an alternative diagnosis. One of the reasons that blood tests are not reliable for accurate peptic ulcer diagnosis on their own is their inability to differentiate between past exposure to the bacteria and current infection. Additionally, a false negative result is possible with a blood test if the patient has recently been taking certain drugs, [18] such as antibiotics or proton pump inhibitors. The diagnosis of Helicobacter pylori can be made by: Urea breath test (noninvasive and does not require EGD); Direct culture from an EGD biopsy specimen; this is difficult to do, and can be expensive. Most labs are not set up to perform H. pylori cultures; Direct detection of urease activity in a biopsy specimen by rapid urease test; Measurement of antibody levels in blood (does not require EGD). It is still somewhat controversial whether a positive antibody without EGD is enough to warrant eradication therapy; Stool antigen test; Histological examination and staining of an EGD biopsy.

The breath test uses radioactive carbon atom to detect H. pylori. To perform this exam the patient will be asked to drink a tasteless liquid which contains the carbon as part of the substance that the bacteria breaks down. After an hour, the patient will be asked to blow into a bag that is sealed. If the patient is infected with H. pylori, the breath sample will contain radioactive carbon dioxide. This test provides the advantage of being able to monitor the response to treatment used to kill the bacteria. The possibility of other causes of ulcers, notably malignancy (gastric cancer) needs to be kept in mind. This is especially true in ulcers of the greater (large) curvature of the stomach; most are also a consequence of chronic H. pylori infection. If a peptic ulcer perforates, air will leak from the inside of the gastrointestinal tract (which always contains some air) to the peritoneal cavity (which normally never contains air). This leads to "free gas" within the peritoneal cavity. If the patient stands erect, as when having a chest X-ray, the gas will float to a position underneath the diaphragm. Therefore, gas in the peritoneal cavity, shown on an erect chest X-ray or supine lateral abdominal X-ray, is an omen of perforated peptic ulcer disease. [edit]Macroscopic

[19]

appearance

A benign gastric ulcer (from the antrum) of a gastrectomy specimen.

Gastric ulcers are most often localized on the lesser curvature of the stomach. The ulcer is a round to oval parietal defect ("hole"), 2 to 4 cm diameter, with a smooth base and perpendicular borders. These borders are not elevated or irregular in the acute form of peptic ulcer, regular but with elevated borders and inflammatory surrounding in the chronic form. In the ulcerative form of gastric cancer the borders are irregular. Surrounding mucosa may present radial folds, as a consequence of the parietal scarring. [edit]Microscopic

appearance

A gastric peptic ulcer is a mucosal defect which penetrates the muscularis mucosae and lamina propria, produced by acid-pepsin aggression. Ulcer margins are perpendicular and present chronic gastritis. During the active phase, the base of the ulcer shows 4 zones: inflammatory exudate, fibrinoid necrosis, granulation tissue and fibrous tissue. The fibrous base of the ulcer may contain vessels with thickened [20] wall or with thrombosis. [edit]Differential

diagnosis

Gastritis Stomach cancer Gastroesophageal reflux disease Pancreatitis Hepatic congestion Cholecystitis Biliary colic Inferior myocardial infarction Referred pain (pleurisy, pericarditis) Superior mesenteric artery syndrome

[edit]Treatment Younger patients with ulcer-like symptoms are often treated with antacids or H2 antagonists before EGD [citation needed] is undertaken. Bismuth compounds may actually reduce or even clear organisms , though the warning labels of some bismuth subsalicylate products indicate that the product should not be used by [21] someone with an ulcer. Patients who are taking nonsteroidal anti-inflammatories (NSAIDs) may also be prescribed a prostaglandin analogue (Misoprostol) in order to help prevent peptic ulcers, which are a side-effect of the NSAIDs. When H. pylori infection is present, the most effective treatments are combinations of 2 antibiotics (e.g. Clarithromycin, Amoxicillin,Tetracycline, Metronidazole) and 1 proton pump inhibitor (PPI), sometimes together with a bismuth compound. In complicated, treatment-resistant cases, 3 antibiotics (e.g. amoxicillin + clarithromycin + metronidazole) may be used together with a PPI and sometimes with bismuth compound. An effective first-line therapy for uncomplicated cases would be Amoxicillin + Metronidazole +Pantoprazole (a PPI). In the absence of H. pylori, long-term higher dose PPIs are often used. Treatment of H. pylori usually leads to clearing of infection, relief of symptoms and eventual healing of ulcers. Recurrence of infection can occur and retreatment may be required, if necessary with other antibiotics. Since the widespread use of PPI's in the 1990s, surgical procedures (like "highly selective vagotomy") for uncomplicated peptic ulcers became obsolete. Perforated peptic ulcer is a surgical emergency and requires surgical repair of the perforation. Most bleeding ulcers require endoscopy urgently to stop bleeding with cautery, injection, or clipping. Ranitidine and famotidine, which are both H2 antagonists, provide relief of peptic ulcers, heartburn, indigestion and excess stomach acid and prevention of these symptoms associated with excessive consumption of food and drink. Ranitidine and famotidine are available over the counter at pharmacies, both as brand-name drugs and as generics, and work by decreasing the amount of acid the stomach [22] produces allowing healing of ulcers. Sucralfate, (Carafate) has also been a successful treatment

Definition
By Mayo Clinic staff

Ulcers

Digestive Health
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Sign up now Peptic ulcers are open sores that develop on the inside lining of your esophagus, stomach and the upper portion of your small intestine. The most common symptom of a peptic ulcer is abdominal pain. Peptic ulcers that occur on the inside of the stomach are called gastric ulcers. Peptic ulcers that occur inside the hollow tube (esophagus) where food travels from your throat to your stomach are called esophageal ulcers. Peptic ulcers that affect the inside of the upper portion of your small intestine (duodenum) are called duodenal ulcers. It's a myth that spicy foods or a stressful job can cause peptic ulcers. Doctors now know that a bacterial infection or some medications not stress or diet cause most peptic ulcers.

http://www.mayoclinic.com/health/peptic-ulcer/DS00242/DSECTION=symptoms

Symptoms
By Mayo Clinic staff Digestive Health
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Sign up now Pain is the most common symptom Burning pain is the most common peptic ulcer symptom. The pain is caused by the ulcer and is aggravated by stomach acid coming in contact with the ulcerated area. The pain typically may: Be felt anywhere from your navel up to your breastbone Be worse when your stomach is empty

Flare at night Often be temporarily relieved by eating certain foods that buffer stomach acid or by taking an acidreducing medication

Disappear and then return for a few days or weeks Other signs and symptoms Less often, ulcers may cause severe signs or symptoms such as:

The vomiting of blood which may appear red or black Dark blood in stools or stools that are black or tarry Nausea or vomiting Unexplained weight loss Appetite changes When to see a doctor See your doctor if you have persistent signs and symptoms that worry you. Over-the-counter antacids and acid blockers may relieve the gnawing pain, but the relief is short-lived. If your pain persists, see your doctor.

Causes
By Mayo Clinic staff

Ulcers

Digestive Health
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Sign up now Peptic ulcers occur when acid in the digestive tract eats away at the inner surface of the esophagus, stomach or small intestine. The acid can create a painful open sore that may bleed. Your digestive tract is coated with a mucous layer that normally protects against acid. But if the amount of acid is increased or the amount of mucus is decreased, you could develop an ulcer. Causes include:

A bacterium. A common cause of ulcers is the corkscrew-shaped bacterium Helicobacter pylori. H. pylori bacteria commonly live and multiply within the mucous layer that covers and protects tissues that line the stomach and small intestine. Often, H. pylori causes no problems. But sometimes it can disrupt the mucous layer and inflame the lining of your stomach or duodenum, producing an ulcer. It's not clear how H. pylori spreads. It may be transmitted from person to person by close contact, such as kissing. People may also contract H. pylori through food and water.

Regular use of pain relievers. Certain over-the-counter and prescription pain medications can irritate or inflame the lining of your stomach and small intestine. These medications include aspirin, ibuprofen (Advil, Motrin, others), naproxen (Aleve, Anaprox, others), ketoprofen and others. Peptic ulcers are more common in older adults who take pain medications frequently, such as might be common in people with osteoarthritis. To help avoid digestive upset, take pain relievers with meals. If you have been diagnosed with an ulcer, make sure your doctor knows this when prescribing any pain reliever. The pain reliever acetaminophen (Tylenol, others) doesn't cause peptic ulcers.

Other medications. Other prescription medications that can also lead to ulcers include medications used to treat osteoporosis called bisphosphonates (Actonel, Fosamax, others).

Risk factors
By Mayo Clinic staff Digestive Health
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Sign up now You may have an increased risk of peptic ulcers if you: Smoke. Smoking may increase the risk of peptic ulcers in people who are infected with H. pylori. Drink alcohol. Alcohol can irritate and erode the mucous lining of your stomach, and it increases the amount of stomach acid that's produced. Have uncontrolled stress. Although stress alone isn't a cause of peptic ulcers, it's a contributing factor. You may undergo stress for a number of reasons an emotionally disturbing circumstance or event, surgery, or a physical trauma, such as a burn or other severe injury.

Complications
By Mayo Clinic staff Digestive Health

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Sign up now Left untreated, peptic ulcers can result in: Internal bleeding. Bleeding can occur as slow blood loss that leads to anemia or as severe blood loss that may require hospitalization or a blood transfusion. Infection. Peptic ulcers can eat a hole through the wall of your stomach or small intestine, putting you at risk of serious infection of your abdominal cavity (peritonitis). Scar tissue. Peptic ulcers can also produce scar tissue that can block passage of food through the digestive tract, causing you to become full easily, to vomit and to lose weight.

Lifestyle and home remedies

By Mayo Clinic staff Digestive Health
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Sign up now You may find relief from the pain of a stomach ulcer if you: Choose a healthy diet. Choose a healthy diet full of fruits, vegetables and whole grains. Not eating vitamin-rich foods may make it difficult for your body to heal your ulcer. Consider switching pain relievers. If you use pain relievers regularly, ask your doctor whether acetaminophen (Tylenol, others) may be an option for you. Control stress. Stress may worsen the signs and symptoms of a peptic ulcer. Examine your life to determine the sources of your stress and do what you can to address those causes. Some stress is unavoidable, but you can learn to cope with stress with exercise, spending time with friends or writing in a journal. Don't smoke. Smoking may interfere with the protective lining of the stomach, making your stomach more susceptible to the development of an ulcer. Smoking also increases stomach acid. Limit or avoid alcohol. Excessive use of alcohol can irritate and erode the mucous lining in your stomach and intestines, causing inflammation and bleeding.

Prevention
By Mayo Clinic staff Digestive Health
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Sign up now You may reduce your risk of peptic ulcer if you: Protect yourself from infections. It's not clear just how H. pylori spreads, but there's some evidence that it could be transmitted from person to person or through food and water. You can take steps to protect yourself from infections, such as H. pylori, by frequently washing your hands with soap and water and by eating foods that have been cooked completely. Use caution with pain relievers. If you regularly use pain relievers that increase your risk of peptic ulcer, take steps to reduce your risk of stomach problems. For instance, take your medication with meals. Work with your doctor to find the lowest dose possible that still gives you pain relief. Avoid drinking alcohol when taking your medication, since the two can combine to increase your risk of stomach upset.
Peptic ulcer disease refers to painful sores or ulcers in the lining of the stomach or first part of the small intestine, called the duodenum. Symptoms of Peptic Ulcer

Bloating Heartburn Nausea or vomiting

Nursing Diagnosis for Peptic Ulcer

Increased risk of GI bleeding and perforation of stomach, related to gastric or intestinal wall erosion. Increased risk of pyloric obstruction as complication of the peptic ulcer. Increased risk of anemia due to acute or chronic GI bleeding, related to ulcer. Pain and heartburn, related to diagnosis of peptic ulcer. Appetite changes and weight changes due to symptoms of the ulcer. Increased risk of aspiration due to vomiting, related to ulcer. Anxiety related to the symptoms of disease and fear of the unknown.

Nursing Intervention For Peptic Ulcer

Assess, report , and record signs and symptoms and reactions to treatment. Monitor fluids input and output closely. Administer antacid agents, analgesics, H2-receptors antagonists, anticholinergics, sedatives as prescribed, monitor for side effects. Monitor clients vital signs and signs of possible GI bleeding or perforation closely. Monitor laboratory tests results (CBC, electrolytes, Hb levels) for abnormal values. Undertake appropriate intervention in case of GI bleeding, vomiting, or perforation. Provide prescribed diet avoid irritating foods, coffee, etc. Prepare client and his family for surgical intervention if required for recurrent ulcer, hemorrhage, or perforation. For client after surgical intervention provide postoperative care and inform about possible postoperative complications, such as dumping syndrome. Provide emotional support to client, explain all procedures to decrease anxiety and to obtain cooperation. Instruct client regarding disease progress, diagnostic procedures, treatment and its complications, home care, daily activities, diet, restrictions and follow-up.

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