Giới thiệu
- Peptic ulcer disease (PUD) is characterized by mucosal damage secondary to pepsin and gastric acid secretion
- It is the principal cause of upper gastrointestinal (GI) hemorrhage
- Most commonly occurs in the stomach and proximal duodenum, infrequently in the lower esophagus, distal duodenum or jejunum
- Suspected in patients with dyspepsia, history of nonsteroidal anti-inflammatory drug (NSAID) use or Helicobacter pylori (H pylori) infection
- Dyspepsia is a non-specific term indicating discomfort in the upper abdomen
- Refractory PUD is considered in patients with ulcer that failed to heal after 8-12 weeks of therapy
- Giant ulcer with size of >2 cm is an atypical type of PUD that is now rarely encountered; biopsy may be needed to rule out gastric cancer
Dịch tễ học
- Incidence of uncomplicated PUD is approximately 1 case per 1,000 person-years while incidence of ulcer complications is approximately 0.7 cases per 1,000 person-years
- Prevalence of PUD is higher in areas endemic for H pylori
- Gastric ulcers are more prevalent in Asia, particularly in Japan, while duodenal ulcers are more commonly diagnosed in Western countries
- Both duodenal and gastric ulcers have increased incidence with age
- Males are more likely to be affected than females
Sinh lý bệnh
- Ulceration occurs when a disruption in the normal processes of the gastric mucosa leads to an imbalance between the stomach's destructive environment and its defenses
- H pylori infection causes pangastritis which increases basal and stimulated gastric acid secretion by inhibiting somatostatin release and stimulating gastrin release
- NSAIDs damage the gastric mucosa mainly through inhibition of prostaglandin synthesis and its cytoprotective effects
- Gastric acid secretion is increased
- Mucus and bicarbonate secretion is inhibited
- Blood flow to the gastric mucosa is significantly reduced
- Damage to surface epithelial cells decreases bicarbonate production leading to further damage to the protective gastric lining
- Once the superficial mucosa is breached, deeper layers are exposed to acid damage
Signs and Symptoms
Clinical Features
- Majority of patients with PUD are asymptomatic
- Epigastric pain is the most common symptom of PUD among symptomatic patients
- Pain of duodenal ulcer usually occurs 2-5 hours after a meal, improves with food or antacid, and sometimes awakens patient at night
- Pain of gastric ulcer occurs shortly after meals and is commonly worsened by food intake
- Other symptoms include indigestion, nausea and vomiting (N/V), loss of appetite, inability to tolerate fatty foods, heartburn, early satiety, bloating, abdominal fullness, weight loss
- N/V are commonly experienced by patients with prepyloric or pyloric channel ulcers
Alarm Features
- May be observed in complicated PUD
- Hematemesis, melena, hematochezia, anemia or orthostatic hypotension may be secondary to GI bleeding
- Progressive dysphagia, recurrent vomiting and early satiety may be due to gastric outlet obstruction
- Anorexia or weight loss may suggest cancer
- Persistent upper abdominal pain radiating to the back may be due to penetration of ulcer into adjacent structures
- Spreading upper abdominal pain that is severe may suggest perforation
Yếu tố nguy cơ
- 70% of cases occur in patients aged 25-64 years old
- Incidence of complicated PUD increases with age
- Most cases are secondary to H pylori infection and use of NSAIDs
- Some evidence states that H pylori infection may be food or water borne and may spread from person to person
- In patients with a bleeding ulcer, it is recommended to test for and treat H pylori
- Patients who are on long-term NSAIDs have an annual risk of life-threatening ulcer-related complication of 1-4%
- H pylori infection and NSAID use increase the risk and intensity of NSAID-related mucosal damage
- Both are the primary causes of PUD complications (eg bleeding and perforation)
- Other risk factors may include drugs (eg low-dose Aspirin, corticosteroids, bisphosphonates, anticoagulants), potassium chloride, chemotherapeutic agents, radiation therapy, presence of acid-hypersecretory states (eg Zollinger-Ellison syndrome), cancer, chronic disease, stress (eg multiorgan failure, ventilator support, extensive burns [Curling’s ulcer] or head injury [Cushing’s ulcer]), viral infection, lifestyle factors (eg diet, alcohol use, smoking), genetic factors