Friday, August 19, 2011

Acid - Peptic Disease/ Peptic Ulcer Disease

Peptic Ulcer disease refers to ulcer in the lower oesophegus, stomach, and duodenum.

Incidence: of peptic ulcer
10% of all adults suffer from peptic ulcer. t is more common in males than females.

What are the mechanisms of acidity?
They are...
1. Strong positive family history.
2. Increased gastric hypersecretion of acid - pepsin juices, which are capable of causing digestion of the stomach mucosa.
3. Decrease of Mucosal resistance of the stomach:

Mucosal resistance of stomach could be decreased due to various reasons
             (a) Infection with Helicopecter Pylori
             (b) Use of Aspirin and other pain killers (NSAID's) for a chronic period. eg. Ibuprofen, Diclofenac, Soadium, Mefenamic acid etc...

NSAIDS are prostaglandin synthesis inhibitors, since prostaglandins are important mediators of pain.

On the other hand, prostaglandins also have an action of increasing the mucosal bloody supply in the stomach and protecting the stomach from acid.  THis is called as Physiological mucosal resistance of the stomach.
Mucosal cells are tightly bounded to each other and so function as a mechanical barrier to protect the stomach from acid damage.  Normally, the epithelial cells of stomach also secrete some bicarbonate in order to neutralize, the acid secretion of the stomach.

This above paragraph is summarized as Mucosal Resistance/ Protecting Mucosal Barriers of Stomach.

CAUSES: of peptic ulcer/ Acid - Peptic
1. Chronic use of  NSAIDS (Non Steroidal Anti Inflammatory Drugs)
2. Severe sepsis
3. Following any surgery (Usually leads to stress ulcers)
4. Following any trauma (Usually leads to stress ulcers)
5. Burns and Shock ( These conditions lead on to ischemia of mucosa which in turn leads to ulcer formation.
7. Infections like typhoid leading on to formation of flask shaped ulcers.
8. Infection with H. Pylori
9. Reflux of bile and other alkaline intestinal contents into the stomach because of poorly functiong pyloric sphincter. (Pyloric sphincter looses its tone) This is because normal physiologic medium of stomach is acidic and not alkaline.

CLINICAL FEATURES: of Peptic Ulcer/ Acid Peptic disease

On and off recurrent pain abdomen there are four characteristics to this pain.
             a). Pain is primarily around the epigestrium.
Patients typically points to this site, locating their pain.  This is, therefore also known as pointing sign.
            b). The pain is typically hanger pain.  i.e. This pain is relieved on taking food/ antacids.  In other words, patient feels much better after taking food/antacids.
            c). This pain is more at night.
            d). Pain is typically episodic each episode lasts about 7 - 10 days, about 4 - 5 times in a year.
2. Water - Brash / Acid- Brash 
This is increased excessive salivation due to increased acidity.

3. Heart - Burn:
Pain in Acid - Peptic disease is burning pain which is mainly retrosternal in location.  This burning retrostrenal chest pain resembles, MI chest pain. (heart attack chest pain.) so, also called as heart- burn.  The diagnosis of MI ( myocardial Infraction) can be confirmed by taking an ECG/ Stress test/ ECHO.  If these all are normal, than cause of burning chest pain is more likely to be ACID - PEPTIC DISEASE.

4. Increased Nausiation and vomiting 

5. Weight loss and loss of Appetite.



1. More common in more than 40 years of age group.

2. Less frequent episodes.

3. More chances of leading to cancer of stomach later (Gastric ulcer is a pre- malignant lesion)

4. Food irritates the ulcer site, more

5. Heart burn less common

6. Night pains less common

7. Strong positive family history is usually present

8. Most common site is pylorus of stomach.

9. Decreased mucosal resistance is primary cause

10. Since food irritates the ulcer site, though pain is lower in intensity lasts longer.


1. More common in youngers ( 20-40 years of age)

2. More frequent episodes

3. not a premalignant lesion. so does not lead to cancer.

4. food relieves the ulcer site.

5. Heart burn more common

6. Night pains more common.

7. No family history present

8. Most common site is duodenum

9. Increased acidity is the primary cause.

10. Since food relieves ulcer site, though pain is more in intensity lasts for short period.


Investigation: of Peptic Ulcer or Acid - Peptic Disease

1. Gastroscopy and Duodenoscopy 

Endoscopy will clearly show the ulcer site.  If it is a gstric ulcer, a biopsy must be taken to rule out carcinoma of stomach.  This is because 10 % of all gastric ulcers are malignant such as gastric ulcers lead on to carcinoma of pylorus and carcinoma of antrum later on.

2. Barrium contrast studies:

It would also reveal the crater of the ulcer.

3. Urea Breath test:

Radioactive labelled urea is ingested.  If H. Pylori is present in the G.I.T it would release urease enzymes.  This enzyme is capable of digesting urea to release ammonia.  Since, urea is radio - active labelled even the ammonia becomes radio - active.  This radio - active ammonia can then be measured in patient's breath by micro- biologist.  If the patient has no H. Pylori in his G.I.T then thre would not be any radio active ammonia in his breath.

TREATMENT: for Peptic Ulcer or Acid Peptic Disease

1. General measures:
  • Avoid smoking
  • Avoid caffeine 
  • Avoid alcohol
  • Avoid aspirin and other NSAIDS
All these decreases pyloric sphincter tone.

2. Antacids:
Most commonly used antacids are a combination of aluminium and magnesium compounds.  They act by neutralizing the acid as they are alkaline in nature.  These should not be misused because they can cause constipation (aluminium) and diarrhoe (magnisium) on long term use.

3. H2 receptor antagonists:
Mechanism of Action: These blocks the H2 receptors in the stomach thereby causing inhibition of acid - pepsin secretion symptoms get relieved in a few days and ulcer begins to heal in a few weeks.  Duration of treatment is usually 4- 6 weeks. 
Most commonly ones are
 cimetidine 400 mg BID orally.  
Gynecomestia : Banitidine - 150 mg BID orally, and 50 mg BID IV. 
Famotidine: 20 mg BID (orally)
Nizatidine: 150 mg BID ( orally)

4. Proton Pump Inhibitors: (PPI)
Mechanism of Action: They block the release of HCL from the stomach by completely blocking the proton pump (H+ ATPase enzyme is blocked) in the parietal cells.
Most commonly used Proton Pump Inhibitors are:
Omeprazol: 20 mg OD for 4 weeks
Pentoprazol: 40 mg OD for 4 weeks
Rabeprazol: 20 mg OD for 4 weeks

Proton Pump Inhibitors are more effective then H2 receptros antagonists in treatment of Acid-Peptic diease because they completely block the release of HCL from stomach.

5. Anti-Cholenergics:
These decrease the HCL secretion by blocking muscarinic receptros in the stomach 
eg. Pirenzepine 
not very commonly used, can cause dryness of mouth.  Moreover, there are other better drugs available in the market.

6. Prostaglandin analogues: 
Mechanism of Action: Strengthens the mucosal barrier and protects the stomach from further acid damage. Eg. Mesoprostol.

7. Sucralfate:
Mechanism of Action: This forms a protective coating over the ulcers and protects it from any further acid destruction. 

8. Colloidal Bismuth compounds:
Mechanism of Action: forms a coat at the ulcer base which protects against any further acid - pepsin digestion of mucosa.

9. H. Pylori kits / regimens:
These are regimens which comprise of a combination of a proton - pump inhibitor + an H2 receptor antagonist + an antibiotic.
Proton Pump Inhibitor could be pentoprozol or omperazol or rabeprazol.
H2 receptor antagonist could be Imetidine, ranitidine or famotidine.
Anti-biotic could be (against H. Pylori)
Amoxycillin, tetracyclin, metronidazol
eg of regimen are COA regimen, COM regimen

10. Surgical Management for ACID - PEPTIC DISEASES:

a) For gastric ulcer:
Surgery of choice is partial gastrectomy followed by Billroth's anastomosis.  In this surgery, the affected pylorus with the antrum is removed and subjected to biopsy to rule out any malignancy.  The stump of stomach and intestine is then closed.  In order to establish continuity with G.I.T and to facilitate continous drainage, the rest of intestines are anastomosed with the stomach.  This is called Billroth's anastomosis

2) For Duodenal Ulcer:
Choice of surgery is vegotomy. This is because the fagus is primarily responsible for nerve supply to the acid producing area of stomach by the denervation of vagus.  The acid secretion and release could be brought under control.  THis is called as trunkal vegatomy.  However, in this procedure all branches of vagus are cut resulting in decreased acidity but also resulting in decreased motility of stomach.  This is because the vagus is not only responsible for acid secretion but also for paristalsis of stomach.  so, the side effect of truncal vegotomy is lack of drainage.  So, an additional drainage procedure should be done, The additional drainage procedure could be of two types.
Pyloroplasty - Repairing pylorus and widening the opening to facilitate drainage
Gastro - Enterostomy: Connecting intestines to stomach to faciliate
The other kind of surgery for a duodenal ulcer is HIGHLY SELECTIVE VEGATOMY.  In this procedure, t only that branch of vagus is cut which is responsible for acid production. The other branches of vagus are saved.  Motility of stomach remains intact.  Advantages of HSV is that no additional drainage procedure is required since propulsive movement of the stomach is preserved in HSV.  The current procedure of choice in HSV. 

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