A peptic ulcer is a breach in the stomach or duodenal lining caused by stomach acid and pepsin. Helicobacter pylori infection and NSAID use are common causes. Symptoms include abdominal pain, nausea, and vomiting of blood in severe cases. Complications can include bleeding, perforation, and scarring that obstruct the stomach. Treatment involves eradicating H. pylori, reducing acid production, and avoiding ulcer-causing factors like NSAIDs and smoking.

1. By JES JENI..
GROUP 8

2.  A peptic ulcer is a distinct breach in the mucosal
lining of the stomach (gastric ulcer) or the first part
of the small intestine (duodenal ulcer), a result of
caustic effects of acid and pepsin in the lumen.
 Histologically, peptic ulcer is identified as necrosis
of the mucosa which produces lesions equal to or
greater than 0.5 cm.
 It is the most common ulcer of an area of the
gastrointestinal tract that is usually acidic and thus
extremely painful.
 Helicobacter pylori is one of the most common
causes of peptic ulcer. Ulcers can also be caused or
worsened by drugs such as aspirin, ibuprofen, and
other NSAIDs.

3.  Gastric ulcers that occur on the
inside of the stomach
 Esophageal ulcers that occur
inside the hollow tube
(esophagus) that carries food
from your throat to your
stomach
 Duodenal ulcers that occur on
the inside of the upper portion
of your small intestine
(duodenum)

4.  Peptic ulcer disease (PUD) may be due to any of the
following:
 H pylori infection
 Drugs
 Lifestyle factors
 Severe physiologic stress
 Genetic factor
 Excess acid production from gastrinomas, tumors of
the acid producing cells of the stomach that increases
acid output

5.  PUD affects between 3.5 and 7.5 million people in the U.S., with
approximately 0.5 million new cases diagnosed every year.
 Despite improvements in treatment, widespread use of NSAIDs
and low-dose aspirin means that the economic burden of PUD
remains significant
 The incidence of PUD has declined significantly in the U.S.,
Europe, and Australia. From 1992 to 1999, the annual rate of
hospitalization for PUD decreased from 205 admissions per
100,000 people to 7.7 admissions per 100,000 people.
 During the same period, the annual mortality rate for PUD
decreased from 165 deaths per 100,000 people to 6 deaths per
100,000 people. This observed trend may be attributable to a
consistent decrease in H. pylori infection in several populations,
especially in wealthy western societies.

6.  In the United States about four million people have active peptic ulcers
and about 350,000 new cases are diagnosed each year. Four times as
many duodenal ulcers as gastric ulcers are diagnosed. Approximately
3000 deaths per year in the United States are due to duodenal ulcer
and 3000 to gastric ulcer.
 In the past, duodenal ulcer was 10 times as common in men as in
women and gastric ulcer had a male preponderance of 3:2.
 PUD affects between 3.5 and 7.5 million people in the U.S., with
approximately 0.5 million new cases diagnosed every year.
 In the U.S., the prevalence of H. pylori among patients over age 60 is
reported to range from 40% to 60% compared to only 10% among
patients aged 20 years

7.  An ulcer may or may not have symptoms. When symptoms
occur, they may include:
 A gnawing or burning pain in the middle or upper stomach
between meals or at night
 Bloating
 Heartburn
 Nausea vomiting
 In severe cases, symptoms can include:
 Dark or black stool (due to bleeding)
 Vomiting blood (that can look like "coffee-grounds")
 Weight loss
 Severe pain in the mid to upper abdomen

10. Esophageal Erosions
 The characteristic
histological finding of PUD
is full ulceration of the
gastric or small intestinal
mucosa to the level of the
sub-mucosa.
 Although the term
ulceration typically refers to
any erosion of the surface
epithelium, the term "Peptic
Ulcer" is reserved for deeper
extents of erosion, into the
sub-mucosa.

11.  This is a more typical
acute gastritis with a
diffusely hyperemic
gastric mucosa. There
are many causes for
acute gastritis:
alcoholism, drugs,
infections, etc.

12.  Gross
 usually less than 20 mm in diameter but
they may > 100 mm in diameter.
 The classic peptic ulcer is a round to
oval, sharply punched-out defect
 In contrast, heaped-up margins are more
characteristic of cancers
 Microscopy
 the base consists of necrotic tissue and
polymorph exsudate overlying inflamed
granulation tissue which merges with
mature fibrous (scar) tissue.

14.  A 1 cm acute
gastric ulcer is shown
here in the upper
fundus. The ulcer is
shallow and sharply
demarcated, with
surrounding hyperemia
and some smaller
ulcers. It is probably
benign.

15.  The endoscopic appearance of a
similar acute peptic ulcer in the
pre-pyloric region is seen .

16. Here is a large 3 x 4 cm gastric ulcer that led to the resection
of the stomach shown here. This ulcer is quite deep with
irregular margins. Complications of gastric ulcers (either
benign or malignant) include pain, bleeding, perforation,
and obstruction.

17. These are gastric ulcers of small, medium, and large size on
upper endoscopy.

18.  Microscopically, the ulcer
here is sharply demarcated,
with normal gastric
mucosa on the left falling
away into a deep ulcer
whose base contains
infamed, necrotic debris.
 An arterial branch at the
ulcer base is eroded and
bleeding.

21. This has allowed corrosive stomach acid to splash upward into
the lower esophagus causing the red inflammation and white
ulcers to form

23.  Chronic peptic
ulcer
Histologic
section through
the ulcer shows
layers of acute
inflammatory
exudate
including fibrin,
acute
inflammation,
chronic
inflammation,
and fibrosis.

24.  The ulcer at the right is
penetrating through the
muscularis and
approaching an artery.
Erosion of the ulcer into
the artery will lead to
another major
complication of ulcers--
hemorrhage. This
hemorrhage can be life
threatening.

25.  Helicobacter gastritis
Helicobacter organisms
may be tested for urease
activity.
 Staining of the gastric
biopsy shows
the characteristic curved
rods embedded in the
mucin layer of the
stomach.

26.  Peptic ulcer
Peptic ulcer can be
identified with a
barium study which
outlines
the penetrating
ulceration.

27.  "Hourglass" stomach
Due to chronic peptic
ulceration there is
fibrosis and contracture
of
the stomach leading to
an hourglass shape as
well as altered mobility.

28.  The following factors raise your risk for peptic ulcers:
 Drinking too much alcohol
 Regular use of aspirin, ibuprofen, naproxen, or other non
steroidal anti-inflammatory drugs (NSAIDs). Taking
aspirin or NSAIDs once in a while is safe for most people.
 Smoking cigarettes or chewing tobacco
 Being very ill, such as being on a breathing machine
 Having radiation treatments
 A rare condition called Zollinger-Ellison syndrome causes
stomach and duodenal ulcers.

29.  Zollinger-Ellison syndrome is a condition in which there is increased
production of the hormone gastrin.
 Most of the time, a small tumor (gastrinoma) in the pancreas or
small intestine produces the extra gastrin in the blood.
 Zollinger-Ellison syndrome is caused by tumors. These growths are
most often found in the head of the pancreas and the upper small
intestine.
 The tumors produce the hormone gastrin and are called gastrinomas.
High levels of gastrin cause production of too much stomach acid.

30.  The mortality rate is 1 in 100,000, a figure which has decreased modestly in
the last few decades.
 When the underlying cause for peptic ulcer disease is successfully treated,
the prognosis (expected outcome) for patients with the condition is
excellent. To help prevent peptic ulcers, avoid the following:
 Alcohol
 Common sources of Helicobacter pylori bacteria (e.g., contaminated food and
water, floodwater, raw sewage)
 Long-term use of non steroidal anti-inflammatory drugs (NSAIDs)
 Smoking

31.  Severe blood loss
 Scarring from an ulcer may make it harder for the stomach to empty
 Perforation or hole of the stomach and intestine
 perforation - A hole develops in the lining of the stomach or small
intestine and causes an infection. Signs of a perforated ulcer include
sudden, severe abdominal pain.
 internal bleeding - Bleeding ulcers can result in significant blood loss
and lead to hospitalization. Signs of a bleeding ulcer
include lightheadedness, dizziness, and black stools.
 scar tissue - thick tissue that develops after an injury. This tissue
makes it difficult for food to pass through your digestive tract. Signs
of scar tissue include vomiting and weight loss.
 melaena are associated with erosion of a large blood vessel