PEPTIC ULCER DISEASE
WHAT YOU WANT TO KNOW
Dr. Mathew Philip & Dr. V. K. Shakeer
Department of Gastroenterology, Lakeshore Hospital, Kochi
Acid peptic disease is a broad entity comprising peptic ulcer, Gastroesophageal reflux disease, non-ulcer dyspepsia and hyper secretory syndromes. The pathogenesis of ulcer disease involves the imbalances between the hyper acidity and defense factors. Defense factors are weakened by H-pylori infection, stress, drugs and smoking. H-pylori infection is the commonest infection in the world affecting 20% of the whole population. Peptic ulcer disease shows 70-100% positivity for H pylori. A fewer percentage of positivity is seen in other dyspeptic disorders and malignancy of stomach. H-pylori cause ulcer disease by a variety of mechanisms including increased gastrin production decreased mucosal defense allowing back diffusion of hydrogen ions and pepsins. It is also weakened by decreased carbonate secretion and mucus production and certain species of H-pylori are more ulcerogenic. Besides H-pylori NSAID and aspirin contributes to 25% of ulcer disease. Other rare causes of ulcer disease include Crohn’s disease, ZE syndrome. Mere presence of H-pylori infection alone is not a sufficient cause for ulcer disease. 80-90% of Indian population is infected with H-pylori infection. However, the lifetime risk of ulcer disease is 1 in 5. Treating H-pylori infection in ulcer disease cures 80-90% of ulcer disease with 5% recurrence. However, the question remains unanswered whether to treat H-pylori infection in asymptomatic and non-ulcer dyspepsia patients. An array of serum immunological tests, breath test and stool test are available for diagnosis of H-pylori infection. However rapid urease test of endoscopic biopsy specimen from antrum of stomach is usually employed for diagnosis in clinical practice. H-pylori infection should be treated in those with gastro duodenal ulcer, history of peptic ulcer disease, MALT lymphoma and family history of gastric cancer. Treatment involves triple drug regime with 2 antibiotics and one Proton pump inhibitors (PPI) for a period of 2 weeks. Rechecking for evidence of eradication is not routinely warranted. However, testing is mandatory in complicated ulcer disease and MALT lymphoma follow up. H-pylori negative ulcers are treated with PPIs and avoidance of NSAIDs.
Endoscopic evaluation is warranted in patients above 40 years with dyspepsia, those with alarming symptoms, complication of ulcer disease like gastric outlet obstruction and bleed, assessment of healing of gastric ulcer and persistent symptoms after treatment. Endoscopy is a useful tool in diagnosing and controlling of bleeding ulcer disease. Various Endoscopic techniques like injection, clipping and coagulation are available for controlling ulcer bleed. Commonly used method is injection therapy and clipping. PPIs also help in controlling ulcer bleed by raising PH and stabilization of clots. Several studies have shown that intra venous PPIs are useful in reducing rebleeding. Age more than 60 years, comorbid illness, in hospital bleed, emergency surgery, the outcome is worse.
NSAIDs cause ulcer disease by several mechanisms. They cause topical injury since they are weakly acidic and non-ionized in acidic medium. They also cause systemic depletion of prostaglandins. Studies have shown that Cox 2 inhibitors are safer than non-selective NSAIDs. There is a lack of correlation between the symptoms and pathology of NSAID induced gastropathy.
40% of the NSAID induced erosions are asymptomatic and majority of NSAID users with dyspepsia do not have endoscopy findings and 60% of NSAID induced complication do not have antecedent GI symptoms. Majority of NSAID users complaining of dyspepsia have normal endoscopic findings
In conclusion most ulcers are H-pylori related and H-pylori negative ulcers are also increasing, the important culprit being NSAIDs. Endoscopic measures are ideal for controlling bleeding from peptic ulcer disease in the majority. Cox 2 inhibitors may be considered gastro safe. All PPI are shown to be equal as far as treatment of ulcers and its complications are concerned.