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Peptic ulcer


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Peptic ulcer

  3. 3. DEFINITION AND DESCRIPTIONDEFINITION AND DESCRIPTION ♥ Peptic ulcers are produced by an imbalance between the gastro- duodenal mucosal defense mechanisms and damaging forces of gastric acid and pepsin, combined with superimposed injury from environmental or immunologic agents. ♥The mucous membrane lining the digestive tract erodes and causes a gradual breakdown of tissue. This breakdown causes a gnawing or burning pain in the upper middle part of the belly (abdomen).
  4. 4. ₪ As many as 80% of ulcers are associated with Helicobacter pylori, a spiral-shaped bacterium that lives in the acidic environment of the stomach. ₪ Ulcers can also be caused or worsened by drugs such as aspirin and other NSAIDs. ₪ Although H. pylori infection is usually contracted in childhood, perhaps through food, water, or close contact with an infected individual. usually doesn't cause problems in childhood, if left untreated it can cause gastritis (the irritation and inflammation of the lining of the stomach), peptic ulcer disease, and even stomach cancer later in life.
  5. 5. ₪ Contrary to general belief, more peptic ulcers arise in the duodenum (first part of the small intestine, just after the stomach) than in the stomach. ₪ Duodenal ulcers usually first occur between the ages of 30-50 years and are twice as common in men as in women. ₪ Stomach (or gastric) ulcers usually occur in people older than 60 years and are more common in women.
  6. 6. Classification ₪ Stomach (called gastric ulcer) ₪ Duodenum (called duodenal ulcer) ₪ Oesophagus (called Oesophageal ulcer) ₪ Types of peptic ulcers: ₪ Type I: Ulcer along the lesser curve of stomach ₪ Type II: Two ulcers present - one gastric, one duodenal ₪ Type III: Prepyloric ulcer ₪ Type IV: Proximal gastroesophageal ulcer ₪ Type V: Anywhere
  8. 8. YEAR NAME OF SCIENTISTS WORK 1900s First discovery of human gastric bacteria 1958 Lykoudis (general practitioner in Greece) Treatment of patients for peptic ulcer disease with antibiotics 1982 Barry Marshall & Robin Warren (Two Australian scientists) Helicobacter pylori was rediscovered as a causative factor for ulcers 1987 First study showing that eradication of the organism reduces duodenal ulcer recurrence 1994 National Institutes of Health convened a Consensus Panel that issued guidelines for management of ulcer cancer, taking H. pylori into account 1996 The Food and Drug Administration approves the first antibiotic for treatment of ulcer disease 1997 Centers for Disease Control and Prevention Launched a national education campaign to inform health care providers and consumers about the link between H. pylori and ulcers.
  9. 9. SYMPTOMS
  10. 10. Gastric versus duodenal ulcer — Although there is much overlap, symptoms of a gastric ulcer may be different than those of a duodenal ulcer. Duodenal ulcer — "Classic" symptoms of a duodenal ulcer include burning, gnawing, aching, or hunger-like pain, primarily in the upper middle region of the abdomen below the breastbone (the epigastric region). Pain may occur or worsen when the stomach is empty, usually two to five hours after a meal. Symptoms may occur at night between 11 PM and 2 AM, when acid secretion tends to be greatest. Feel better when you eat or drink and then worse 1 or 2 hours later (duodenal ulcer) Gastric ulcer — Symptoms of a gastric ulcer typically include pain soon after eating. Symptoms are sometimes not relieved by eating or taking antacids. Feel worse when you eat or drink (gastric ulcer)
  11. 11. SYMPTOMS Burning painBurning pain bloatingbloating NauseaNausea water brashwater brash Unexplained weight lossUnexplained weight loss hematemesis (vomiting of blood)hematemesis (vomiting of blood) Appetite changesAppetite changes MelinaMelina vomitingvomiting Blood in the stoolsBlood in the stools low blood cell count (anemia)low blood cell count (anemia) Stomach pain wakes you up at nightStomach pain wakes you up at night frequent burping or hiccuppingfrequent burping or hiccupping An early sense of fullness with eatingAn early sense of fullness with eating
  13. 13. stretch receptors Medulla oblongata endocrine cells gastrinCirculatory system stomach secretes gastric juice
  14. 14. й Helicobacter pylori, a bacteria that is frequently found in theHelicobacter pylori, a bacteria that is frequently found in the stomachstomach й Nonsteroidal anti-inflammatory drugs (NSAIDS) such asNonsteroidal anti-inflammatory drugs (NSAIDS) such as ibuprofenibuprofen й In addition, smoking and certain other genetic andIn addition, smoking and certain other genetic and environmental factors (such as medications) may influence theenvironmental factors (such as medications) may influence the course of peptic ulcer disease.course of peptic ulcer disease. й Psychological stress and dietary factors were once thought to bePsychological stress and dietary factors were once thought to be the cause of ulcers, although these factors are no longer thoughtthe cause of ulcers, although these factors are no longer thought have a major role.have a major role.
  15. 15. Helicobacter pylori infectionHelicobacter pylori infection
  16. 16. Helicobacter pylori infection ¤H. pylori is a helix-shaped ¤ Gram-negative, slow-growing organism ¤ about 3 micrometres long with a diameter of about 0.5 micrometres ¤has 4–6 flagella ¤ Helicobacter pylori is composed of a single circular chromosome with 1,667,867 base pairs, containing about 1590 coding regions ¤It is microaerophilic; that is, it requires oxygen, but at lower concentration than is found in the atmosphere ¤It contains a hydrogenase which can be used to obtain energy by oxidizing molecular hydrogen (H2) that is produced by intestinal bacteria
  17. 17. * It produces oxidase, catalase, and urease * It is capable of forming biofilms and can convert from spiral to a possibly viable but nonculturable coccoid form, both likely to favor its survival and be factors in the epidemiology of the bacterium.
  19. 19. Molecular model of H. pylori urease enzyme
  20. 20. ☻The bacterium persists in the stomach for decades in most people. Most individuals infected by H. pylori will never experience clinical symptoms despite having chronic gastritis. Approximately 10-20% of those colonized by H. pylori will ultimately develop gastric and duodenal ulcers. H. pylori infection is also associated with a 1-2% lifetime risk of stomach cancer and a less than 1% risk of gastric MALT lymphoma
  21. 21. • Regular use of pain relievers. Nonsteroidal anti- inflammatory drugs (NSAIDs) can irritate the lining of stomach and small intestine. These medications, which are available both by prescription and over-the-counter, include aspirin, ibuprofen (Advil, Motrin, others), naproxen (Aleve), ketoprofen and others. Other prescription medications that can also lead to ulcers include medications used to treat osteoporosis called bisphosphonates (Actonel, Fosamax and others). • NSAIDs inhibit production of an enzyme (cyclooxygenase) that produces prostaglandins. These hormone-like substances help protect stomach lining from chemical and physical injury. Without this protection, stomach acid can erode the lining, causing bleeding and ulcers.
  22. 22. ♣ Effects of smoking on PUDEffects of smoking on PUD ♣Increased rate of gastric emptyingIncreased rate of gastric emptying ♣Diminished pancreatic bicarbonate secretionDiminished pancreatic bicarbonate secretion ♣Decreased duodenal pHDecreased duodenal pH ♣Reduced mucosal blood flowReduced mucosal blood flow ♣Inhibition of mucosal prostaglandinsInhibition of mucosal prostaglandins
  23. 23. NICOTINE parasympathetic nerveparasympathetic nerve activity inactivity in gastrointestinal tractgastrointestinal tract increase stimulation tostimulation to the enterochromaffin-like cellsthe enterochromaffin-like cells and G cellsand G cells increases theincreases the amountamount of histamine andof histamine and gastrin secretedgastrin secreted
  24. 24. • Gastrinomas (Zollinger Ellison syndrome), rare gastrin-secreting tumors, also cause multiple and difficult to heal ulcers. • Excessive alcohol consumption Alcohol can irritate and erode the mucous lining of stomach and increases the amount of stomach acid that's produced. It's uncertain, however, whether this alone can progress into an ulcer or if it just aggravates the symptoms of an existing ulcer.
  25. 25. • Caffeine Beverages and foods that contain caffeine can stimulate acid secretion in the stomach. This can aggravate an existing ulcer, but the stimulation of stomach acid can't be attributed solely to caffeine.
  26. 26. Role of StressRole of Stress ♫ A study of peptic ulcer patients in a Thai hospital showed that chronic stress was strongly associated with an increased risk of peptic ulcer, and a combination of chronic stress and irregular mealtimes was a significant risk factoR. ♫ An expert panel convened by the Academy of Behavioral Medicine Research concluded that ulcers are not purely an infectious disease and that psychological factors do play a significant role. Researchers are examining how stress might promote H. pylori infection. ♫ For example, Helicobacter pylori thrives in an acidic environment, and stress has been demonstrated to cause the production of excess stomach acid. This was supported by a study on mice showing that both long-term water-immersion- restraint stress and H. pylori infection were independently associated with the development of peptic ulcers. ♫ Physical stress, is different. It can increase the risk of developing ulcers, especially in the stomach. Examples of physical stress that can lead to ulcers are that suffered by people with injuries such as severe burns, and people undergoing major surgery.
  27. 27. ‫אָ‬ 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-phenomena independent of the progress in treatment of the disease. The cohort-phenomena is probably explained by improved standards of living which has lowered the incidence of H. pylori infections.
  28. 28. Risk Factors for UlcersRisk Factors for Ulcers
  29. 29. • You’re at risk for peptic ulcer disease if you: • Are 50 years old or older. • Diabetes may increase your risk of having H. pylori • Drink alcohol excessively • Smoke cigarettes or use tobacco. • Have a family history of ulcer disease. • You’re at risk for NSAID-induced ulcers if you: • Are age 60 or older (your stomach lining becomes more fragile with age). • Have had past experiences with ulcers and internal bleeding • Take steroid medications, such as prednisone. • Take blood thinners, such as warfarin. • Consume alcohol or use tobacco on a regular basis. • Experience certain side effects after taking NSAIDs, such as upset stomach and heartburn. • Take NSAIDs in amounts higher than recommended • Take NSAIDs for long periods of time • Stress does not cause an ulcer, but may be a contributing factor • Chronic disorders such as liver disease, emphysema, rheumatoid arthritis may increase vulnerability to ulcers • Improper diet, irregular or skipped meals • Type O blood (for duodenal ulcers)
  31. 31. ж Gastrointestinal bleeding is the most common complication. Sudden large bleeding can be life- threatening. It occurs when the ulcer erodes one of the blood vessels. Bleeding can occur as slow blood loss that leads to anemia or as severe blood loss that may require hospitalization or a blood transfusion. ж Perforation (a hole in the wall) often leads to catastrophic consequences. Erosion of the gastro- intestinal 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 acute peritonitis, initially chemical and later bacterial peritonitis. The first sign is often sudden intense abdominal pain. Posterior wall perforation leads to pancreatitis; pain in this situation often radiates to the back.
  32. 32. ж Penetration is when the ulcer continues into adjacent organs such as the liver and pancreas ж Scar tissue Scarring and swelling due to ulcers causes narrowing in the duodenum and gastric outlet obstruction. Patient often presents with severe vomiting. Peptic ulcers can also produce scar tissue that can obstruct passage of food through the digestive tract, causing you to become full easily, to vomit and to lose weight.
  33. 33. WARNING SIGNSWARNING SIGNS blood in your stoolsblood in your stools losing weightlosing weight pain doesn't go awaypain doesn't go away With medicationWith medication vomit bloodvomit blood sudden, severe painsudden, severe pain vomit food eaten hours orvomit food eaten hours or days beforedays before ongoing nausea orongoing nausea or repeated vomiting.repeated vomiting. feel cold or clammyfeel cold or clammy feel unusually weak orfeel unusually weak or dizzydizzy
  35. 35. Noninvasive Urea Breath Test (UBT) Blood test Invasive Biopsy Urease TestHistology
  36. 36. Culture Stool antigen test Upper gastrointestinal (upper GI) X-ray Other tests Endoscopy
  37. 37. TREATMENT
  38. 38. GOALS OF TREATMENT ☻ lowering the amount of acid that stomach makes, ☻neutralizing the acid ☻ protecting the injured area so it can heal ☻ It's also very important to stop smoking and drinking alcohol ☻Prevent complications (bleeding, perforation, penetration, obstruction) ☻Minimize recurrences ☻Reduce financial costs
  39. 39. Antibiotic medications. Doctors use combinations of antibiotics to treat H. pylori because one antibiotic alone isn't always sufficient to kill the organism. Antibiotics prescribed for treatment of H. pylori include amoxicillin (Amoxil), clarithromycin (Biaxin) and metronidazole (Flagyl). Combination drugs that include two antibiotics together with an acid suppressor or cytoprotective agent (Helidac, Prevpac) have been designed specifically for the treatment of H. pylori infection. Acid blockers. Acid blockers — also called histamine (H-2) blockers — reduce the amount of hydrochloric acid released into digestive tract, which relieves ulcer pain and encourages healing. Acid blockers work by keeping histamine from reaching histamine receptors. Histamine is a substance normally present in body. When it reacts with histamine receptors, the receptors signal acid-secreting cells in stomach to release hydrochloric acid. Available by prescription or over-the-counter (OTC), acid blockers include the medications ranitidine (Zantac), famotidine (Pepcid), cimetidine (Tagamet) and nizatidine (Axid). Antacids. An antacid may be taken in addition to an acid blocker or in place of one. Instead of reducing acid secretion, antacids neutralize existing stomach acid and can provide rapid pain relief.
  40. 40. ♪ Proton pump inhibitors. Another way to reduce stomach acid is to shut down the "pumps" within acid-secreting cells. Proton pump inhibitors reduce acid by blocking the action of these tiny pumps. These drugs include the prescription and over-the-counter medications omeprazole (Prilosec), lansoprazole (Prevacid), rabeprazole (Aciphex) and esomeprazole (Nexium). Doctors frequently prescribe proton pump inhibitors to promote the healing of peptic ulcers. Proton pump inhibitors also appear to inhibit H. pylori. ♪ Cytoprotective agents. In some cases, your doctor may prescribe these medications that help protect the tissues that line your stomach and small intestine. They include the prescription medications sucralfate (Carafate) and misoprostol (Cytotec). Another nonprescription cytoprotective agent is bismuth subsalicylate (Pepto-Bismol). ♪ Bowel rest: Bed rest and clear fluids with no food at all for a few days. This gives the ulcer a chance to start healing without being irritated. ♪ Nasogastric tube: Placement of a thin, flexible tube through your nose and down into your stomach. This also relieves pressure on the stomach and helps it heal. ♪ Urgent endoscopy or surgery if indicated: Damaged, bleeding blood vessels can usually be repaired with an endoscope. The endoscope has a small heating device on the end that is used to cauterize a small wound.
  41. 41. SurgerySurgery Vagotomy Antrectomy Pyloroplasty Tying off an artery Acupuncture Chiropractic Homeopathy Herbs Other modes Of treatment
  43. 43. Don't smokeDon't smoke Limit or avoid alcoholLimit or avoid alcohol Avoid nonsteroidalAvoid nonsteroidal anti-inflammatoryanti-inflammatory drugs (NSAIDs)drugs (NSAIDs) Fruits andFruits and VegetablesVegetables LessLess Coffee andCoffee and CarbonatedCarbonated BeveragesBeverages Use of Olive OilUse of Olive Oil ExerciseExercise Stress ReliefStress Relief