Peptic Ulcer Disease (Stomach Ulcers)

Peptic ulcer disease is common. Patients usually complain of upper abdominal pain, dyspepsia, water-brash, chest pain, difficulty breathing, belching and feeling of bloatedness. Peptic ulcer disease comprise of gastritis and stomach or duodenal ulcers.

The main causes are:
-ingestion of NSAIDs such as aspirin, voltaren, ponstel/ponstan (mefenemic acid)
-H. Pylori infection
-stress
-stomach cancer or lymphoma
-hiatus hernia
-hyperparathyroidism
-Zollinger-Ellison syndrome (a tumour of the pancreas which produces the hormone gastrin which increases stomach acid secretion)

The development of peptic ulcers is due to the imbalance between protective factors and aggressive factors. Protective factors include mucin, bicarbonate and prostaglandins which are naturally secreted by the cells from the stomach. Aggressive factors include H. pylori, NSAIDs and excessive acid secretion from the stomach.

Stomach ulcer

Helicobacter pylori is a bacteria which causes inflammation of the stomach mucosa. Certain strains are more virulent such as the CaG and VacA which promotes the release of pro-inflammatory substances in the stomach. H. pylori infection is also a risk factor for stomach cancer. It is classified as a carcinogen.

NSAIDs cause peptic ulcers by reducing the secretion of protective prostaglandins from the stomach. It is a known side effect of the drug due to inhibition of cyclo-oxygenase (COX). The newer selective COX-2 inhibitor NSAIDs (eg celecoxib, etoricoxib) causes less gastric complications.

Patients who are <55 years old and with symptoms of peptic ulcer disease can undergo non-invasive investigations such as:
- Urea breath test: 95% sensitive in detecting H. pylori infection
- H. pylori serology blood test: >80% sensitive in detecting the infection
- Stool H. pylori antigen test: >90% sensitive in detecting the infection

Patients who are >55 years old or have "Alarm Symptoms" should undergo an urgent OesophagoGastroDuodenoScopy (OGDS/EGDS).
Alarm Symptoms include:
- weight loss
- difficulty swallowing
- vomiting blood or passing blackish stools
- anaemia
- a palpable mass in the upper abdomen
- persistent vomiting

OGDS/EGDS: the fibre-optic scope

OGDS/EGDS is a simple day-care procedure where a small fibre-optic scope is passed thru the patients' mouth into the stomach to visualise the oesophagus, stomach and duodenum. It can be done with or without sedation. The advantages of OGDS is that it is able to diagnose the disease and also localise it. Pictures can be taken of the ulcer areas to compare after treatment. Biopsies can be taken for H.pylori hustology and also for suspicious stomach tumours.

View from OGDS of a normal stomach at the pylorus

The treatment for mild gastritis includes:

-dietary advice to avoid sour & spicy foods

-reduce alcohol and stop smoking

-antacids

-H2-blockers such as ranitidine tablets

Patients with H. pylori infection should be treated with a combination of antinbiotics and proton-pump inhibitors (PPI). The first line therapy include:

-Clarithromycin + Amoxycillin + PPI (pentoprazole/esomeprazole) for 2 weeks

Patients who are allergic to penicillin should be treated with:
-Clarithromycin + Metronidazole + PPI

Patients who do not respond to first line therapy should be treated with:

-PPI + Bismuth + Tetracycline + Metronidazole

Post treatment, the patients should get a repeat Urea Breath Test to confirm that the infection has resolved. And these patients should be continued on PPIs for another 1 - 2 months.  

Complications of peptic ulcers include:

-Perforated gastric ulcer

-Bleeding from the ulcers

-Erosion and penetration into other organs

-Gastric outlet obstruction