Many research efforts are currently under way in the field of peptic ulcer disease.
Research Efforts in Peptic Ulcer Disease
Author
Lars Grimm, MD, MHS
House Staff
Department of Internal Medicine
Duke University Medical Center
Durham, North Carolina
Lars Grimm, MD, MHS, has disclosed no relevant financial relationships.
Editor
David A. Johnson, MD
Professor of Medicine
Chief of Gastroenterology
Eastern Virginia Medical School
Norfolk, Virginia
David A. Johnson, MD, has disclosed the following relevant financial relationships:
Served as an advisor or consultant for: AstraZeneca Pharmaceuticals LP, Takeda
Pharmaceuticals North America, Inc.; Eisai Inc.; Novartis Pharmaceuticals
Corporation.
Served as a speaker or a member of a speakers bureau for: AstraZeneca
Pharmaceuticals LP; Takeda Pharmaceuticals North America, Inc.
Received grants for clinical research from: AstraZeneca Pharmaceuticals LP;
Takeda Pharmaceuticals North America, Inc.
Peptic ulcer disease is one of the most common disorders in the United States, accounting for a significant portion of visits to medical providers. Over the last 2 decades significant advances have been made in understanding the pathophysiology of peptic ulcer disease. This has led to significant changes in its incidence, detection, treatment, and mortality. The image shown is a gross pathology sample of a gastric ulcer.
The incidence of outpatient and inpatient care visits for peptic ulcer disease has steadily declined in the United States since the 1970s. The mortality from peptic ulcer disease has similarly decreased over the same interval, which has been attributed to increased Helicobacter pylori eradication rates and the widespread adoption of acid-suppression medications. Image courtesy of the National Institutes of Health.
Source: Everhart JE. Peptic ulcer disease. In: Everhart JE, ed. The Burden of Digestive Diseases in the United States. Washington, DC: US Government Printing Office; 2008. NIH publication no. 09-6443. Available at: http://www2.niddk.nih.gov/AboutNIDDK/ReportsAndStrategicPlanning/BurdenOfDisease/
DigestiveDiseases/. Accessed November 23, 2009.
Peptic ulcers are defects in the gastric or duodenal mucosa that extend through the muscular mucosa (shown). They develop when peptic acid secretion outpaces the gastroduodenal mucosal defense mechanisms. These defense mechanisms include tight intercellular junctions, mucus production, mucosal blood flow, cellular restitution, and epithelial renewal. Patients may report epigastric pain, nausea, vomiting, dyspepsia, heartburn, chest discomfort, anorexia, weight loss, hematemesis, or melena. On physical examination, patients with uncomplicated peptic ulcer disease may exhibit epigastric tenderness, melena, or hemoccult-positive stools. In cases of complicated ulcers, a succussion splash from obstruction may be present. Image courtesy of Wikimedia Commons.
Among the most common etiologies of peptic ulcer disease are H pylori infection (shown) and nonsteroidal anti-inflammatory drug (NSAID) usage, although the prevalence of H pylori infection has been declining. Other more obscure etiologies include hypersecretory states, such as Zollinger-Ellison syndrome, G-cell hyperplasia, mastocytosis, and basophilic leukemias. Image courtesy of Wikimedia Commons.
Sources:
Chey WD, Wong BC, and the Practice Parameters Committee of the American College of Gastroenterology. American College of Gastroenterology guideline on the management of Helicobacter pylori infection. Am J Gastroenterol. 2007;102:1808-1825.
Everhart JE. Peptic ulcer disease. In: Everhart JE, ed. The Burden of Digestive Diseases in the United States. Washington, DC: US Government Printing Office; 2008. NIH publication no. 09-6443. Available at: http://www2.niddk.nih.gov/AboutNIDDK/ReportsAndStrategicPlanning/BurdenOfDisease/
DigestiveDiseases/. Accessed November 23, 2009.
The diagnosis of H pylori infection can be made by a fecal antigen test, carbon-13 urea breath test, serology, or biopsy. Histologic slides can be stained with Giemsa, Warthin-Starry silver, or hematoxylin and eosin. A rapid urease test may demonstrate the presence of the H pylori in the gastric mucosa via histochemistry (shown). Image courtesy of Wikimedia Commons.
Upper gastrointestinal endoscopy is the procedure of choice for the diagnosis of suspected peptic ulcer disease. It is highly sensitive and allows for direct visualization, with the potential for biopsy and cytologic brushing of suspected lesions. The endoscopy image shown is from a 35-year-old woman who presented with tarry stools and a hemoglobin level of 75 g/L.
A number of different visual clues can help differentiate benign from malignant ulcers. Benign ulcers typically have smooth, regular, rounded edges with a flat, smooth base and radiating mucosal folds. Malignant ulcers typically have irregular, heaped or overhanging margins, with an ulcerated mass that protrudes into the lumen and surrounding mucosal folds and which is nodular and irregular. The endoscopic image shown has irregular, heaped margins and was found to be gastric cancer.
Double-contrast upper gastrointestinal series are useful alternatives to endoscopy in the detection of peptic ulcers (blue arrow). They have the advantage of being less expensive and noninvasive, but double-contrast upper gastrointestinal series are not as sensitive as endoscopy, especially for smaller ulcers. Patients ingest effervescent granules and a high-density barium suspension. Manipulating the position of the patient will allow for visualization of ulcers in different portions of the stomach or duodenum.
On double-contrast upper gastrointestinal series a number of features can help distinguish benign from malignant ulcers. The following features are associated with benign ulcers: projection beyond the lumen on profile view, sharp margins that are smooth en face, smooth and symmetric filling defects, and mucosal folds that radiate to the edge of the ulcer (shown). In contrast, the following features are associated with malignant ulcers: intraluminal ulcer crater locations, irregular and nodular margins, fundal location, clubbed mucosal folds that terminate short of the ulcer crater, and a surrounding asymmetrical mass.
Gastric ulcer perforation may occur in as many as 10% of patients with peptic ulcer disease, most commonly from ulcers in the duodenal cap. Such perforations may be detected by free air under the diaphragm on an erect chest x-ray (shown), subphrenic gas and fluid collections seen on computed tomography scan or ultrasonograms, and contrast extravasation on an upper gastrointestinal series with water-soluble contrast material.
Bleeding is another major potential complication of peptic ulcers due to the rich vascular supply of the stomach and duodenum. As the ulcer erodes through the superficial layers of the gastrointestinal tract it can expose the underlying blood vessels. Depending on the volume of blood liberated, patients may present somewhere on the spectrum from transient melena to hemodynamic instability.
Treatment for peptic ulcers is aimed at removing risk factors (eg, NSAID use) and restoring the balance between acid secretion and mucosal protection. Histamine 2 blockers, proton-pump inhibitors, and mucosal protectants are first-line therapeutic agents.
For patients with H pylori infection, eradication can be performed with one of several combination regimens. The table shown lists the initial recommended regimens for H pylori eradication according to the American College of Gastroenterology. Of note, not all of the recommendations are FDA approved.
Source: Chey WD, Wong BC, and the Practice Parameters Committee of the American College of Gastroenterology. American College of Gastroenterology guideline on the management of Helicobacter pylori infection. Am J Gastroenterol. 2007;102:1808-1825.
Patients with active bleeding from a peptic ulcer, as visualized on endoscopy (shown), will need emergent procedural intervention. This can be done with one of several techniques: epinephrine injection, heater-probe coagulation, bipolar electrode coagulation, laser coagulation, clipping, banding, or argon laser coagulation. Perforated peptic ulcers in a patient with peritoneal signs require urgent exploratory laparotomy. The exact procedure performed is dependent on the ulcer location, extent of bleeding, and patient condition.
Many research efforts are currently under way in the field of peptic ulcer disease.
Research Efforts in Peptic Ulcer Disease
Author
Lars Grimm, MD, MHS
House Staff
Department of Internal Medicine
Duke University Medical Center
Durham, North Carolina
Lars Grimm, MD, MHS, has disclosed no relevant financial relationships.
Editor
David A. Johnson, MD
Professor of Medicine
Chief of Gastroenterology
Eastern Virginia Medical School
Norfolk, Virginia
David A. Johnson, MD, has disclosed the following relevant financial relationships:
Served as an advisor or consultant for: AstraZeneca Pharmaceuticals LP, Takeda Pharmaceuticals North America, Inc.; Eisai Inc.; Novartis Pharmaceuticals Corporation.
Served as a speaker or a member of a speakers bureau for: AstraZeneca Pharmaceuticals LP; Takeda Pharmaceuticals North America, Inc.
Received grants for clinical research from: AstraZeneca Pharmaceuticals LP; Takeda Pharmaceuticals North America, Inc.
