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·        Can occur:

o       In esophagus.

o       In jejunum in Zollinger-Ellison syndrome (↑ Gastrin à HCl).

o       After gastroenterostomy.

o       In Meckel’s diverticulum (contains ectopic gastric mucosa).

Epidemiology

·        Duodenal ulcer  (DU) > Gastric ulcer (GU).

·        DU in  ♂ >  ♀.

·        Incidence:  ↑ with age.

Etiology

1.    H. pylori.

2.    Genetic susceptibility.

3.    NSAIDs (mainly for Gastric ulcer).

4.    Hyperthyroidism (Ca⁺² à acid secretion).

5.    Zollinger-Ellison syndrome (hyperacidity state).

Pathology

·        Gastric ulcer may occur in any part of stomach, but is most commonly in lesser curve.

·        Most duodenal ulcers occur in duodenal cap.

Clinical  Features

Symptoms:

  1.         Epigastric pain:  characteristic, pt points directly to epigastrium.

  2.         Indigestion.

  3.         Nausea, heartburn (due to acid regurgitation).

  4.         Anorexia & weight loss (esp. in gastric ulcer).

N.B.  Patients can present for the 1^st time with major complications: e.g. hematemesis / malena / perforation.

N.B. In gastric ulcer, pain is aggravated by food.

Signs:

Epigastric tenderness:  But it does not necessarily imply disease & is usually found in non-ulcer dyspepsia.

N.B. Physical exam is of little help in establishing diagnosis of uncomplicated peptic ulcer diseases.

Investigations

1.     Endoscopy:  1^st  Investigation with biopsy of all gastric ulcers.

2.     Barium meal (double-contrast technique).

Treatment

1.     Eradication of H. pylori.

2.     Omeprazole.

3.     H₂ receptor antagonists.

4.     Stop smoking & NSAIDs.

5.     Surgery.

Surgical Mx

·        Currently surgery is reserved for complications. In the past, 2 types of operation were performed:

1.     Partial gastrectomy:  to remove antral area that secretes gastrin.

a.   Billroth I partial gastrectomy  à best for GU

b.   Billroth II (Polya gastrectomy)          à GU / DU.

2.     Vagotomy:

a.      Truncal vagotomy + gastroenterostomy / pyloroplasty.

b.     Selective vagotomy + gastroenterostomy / pyloroplasty.

c.    Highly selective vagotomy

o       Proximal gastric vagotomy.

o       Nerves supplying parietal cells are transected.

Long-term   Complications  of  surgery

   1.     Recurrence of ulcer with same symptoms.

   2.     Dumping:

o       Nausea, distension associated with sweating, faintness, palpitations.

o       Occurs in patients following gastrectomy / gastroenterostomy.

o       Due to dumping of food into jejunum à rapid fluid dilution of the high osmotic load.

o       Not a clinical problem.

      3.     Diarrhea:  seen after vagotomy.

      4.     Vomiting (Afferent loop syndrome / bilious vomiting).

§        Because food gets trapped owing to altered anatomy.

      5.     Nutritional complications:  Most commonly Fe⁺ def anemia caused by poor absorption.

Complications

H. pylori eradication is imperative.

1.      Hemorrhage.

2.      Penetration.

3.      Perforation.

·        More in duodenal ulcers (usually in peritoneal cavity).

·        May occur in lesser sac.

·        Diagnosis:  air under diaphragm.

4.      Fibrosis:

a.   Hourglass stomach.

b.   Teapot stomach.

c.    Pyloric stenosis / obstruction:

·        Gastric outflow obstruction.

·        Occur in prepyloric / duodenum.

·        Occurs because:

1.     Of active ulcer with surrounding edema.

2.     Healing has been followed by scaring.

3.     Gastric malignancy.

4.     External compression from a pancreatic cancer.

·        Main symptom:  projectile vomiting (no bile).

·        On physical examination:  abdomen has succussion splash.

·        Diagnosis:  Barium meal (soap-plate appearance).

·        Most patients require surgery.  

written by: Khalid Bin Yaroof. FMHS, UAE University.