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Gastric and duodenal ulcers are breaks in the gastric and duodenal mucosa. Both gastric and duodenal ulcers relate to the corrosive action of pepsin and hydrochloric acid on the mucosa of the upper gastrointestinal tract. Ulcers generally range between 3 mm and several centimeters in diameter. Peptic ulcer disease represents a serious medical problem. Approximately 500,000 new cases are reported each year, with 5 million people affected in the United States alone. Interestingly, those at the highest risk of contracting peptic ulcer disease are those generations born around the middle of the 20th century. Ulcer disease has become a disease predominantly affecting the older population, with the peak incidence occurring between 55 and 65 years of age. In men, duodenal ulcers were more common than gastric ulcers; in women, the converse was found to be true. Thirty-five percent of patients diagnosed with gastric ulcers will suffer serious complications. Although mortality rates from peptic ulcer disease are low, the high prevalence and the resulting pain, suffering, and expense are very costly.

Ulcers can develop in the esophagus, stomach or duodenum, at the margin of a gastroenterostomy, in the jejunum, in Zollinger-Ellison syndrome, and in association with a Meckel's diverticulum containing ectopic gastric mucosa. Peptic ulcer disease is one of several disorders of the upper gastrointestinal tract that is caused, at least partially, by gastric acid. Patients with peptic ulcer disease may present with a range of symptoms, from mild abdominal discomfort to catastrophic perforation and bleeding.

Most patients with peptic ulcer disease present with abdominal discomfort, pain or nausea. The pain is located in the epigastrium and usually does not radiate. However, these symptoms are neither sensitive nor specific. Pain radiating to the back may suggest that an ulcer has penetrated posteriorly, or the pain may be pancreatic in origin. Pain radiating to the right upper quadrant may suggest disease of the gallbladder or bile ducts. Patients may describe the pain of peptic ulcer as burning or gnawing, or as hunger pains slowly building up for 1–2 hours, then gradually decreasing. Use of antacids may provide temporary relief. Classically, gastric ulcer pain is aggravated by meals, whereas the pain of duodenal ulcers is relieved by meals. Hence, patients with gastric ulcers tend to avoid food and present with weight loss, while those with duodenal ulcers do not lose weight. It is important to remember that although these patterns are typical, they are not pathognomonic. The nature of the presenting symptoms alone does not permit a clear differentiation between benign ulcers and gastric neoplasm.

Incidents of peptic ulcer disease have been linked to one or more of the following

  • Hypercalcemia
  • Genetic Factors
  • Smoking
  • Stress
  • Alcohol and Diet

Peptic ulcer disease is suspect in patients with epigastric distress and pain; however, these symptoms are not specific. Lack of response to conventional treatment for peptic ulcer disease should suggest conditions other than benign peptic ulcers, and should warrant any of the following diagnostic tests

  • Abdominal imaging.
  • Radiological Diagnosis
  • Laboratory Testing
  • Urea breath tests
  • Stool antigen testing
  • Endoscopic Diagnosis
  • Gastrointestinal endoscopy
  • Esophagogastroduodenoscopy

The goal of therapy for peptic ulcer disease is to relieve symptoms, heal craters, prevent recurrences, and prevent complications. Medical therapy should include treatment with drugs, and attempt to accomplish the following:

  • Reduce gastric acidity by mechanisms that inhibit or neutralize acid secretion,
  • Coat ulcer craters to prevent acid and pepsin from penetrating to the ulcer base,
  • Provide a prostaglandin analog,
  • Remove environmental factors such as NSAIDs and smoking, and
  • Reduce emotional stress (in a subset of patients).

Antacids neutralize gastric acid and are more effective than placebo in healing gastric and duodenal ulcers. However, antacids have to be taken in relatively large doses 1 and 3 hours after meals and at bedtime, and may cause side effects. The major side effect of magnesium-containing antacids is diarrhea caused by magnesium hydroxide.

SURGICAL THERAPY

Over the past few decades in the United States, we have witnessed a declining need for surgery to treat peptic ulcer disease. This decline may be explained primarily by the widespread use of H2 receptor antagonists, and now more recently, proton pump inhibitors. Complications such as gastrointestinal hemorrhage, perforation, or gastric outlet obstruction remain the major indications for surgical intervention.

The most common reason for surgical intervention for benign gastric ulcers is failure of the ulcer to completely heal after an adequate trial of medical or endoscopic therapy. Patients are usually given a 6-month trial of anti-secretory agents prior to surgical consultation. The major concern regarding non-healed ulcers is the high risk of underlying malignancies.

Due to the benign nature of duodenal ulcers, physicians can monitor the patients’ response to medical regimens by following their symptoms. When patients with duodenal ulcers require surgery, it is usually one of three procedures: vagotomy, vagotomy with antrectomy, or subtotal gastrectomy . Vagotomy alone (without gastric resection) may involve truncal vagotomy with drainage, selective vagotomy with drainage (Figure 18), or proximal gastric vagotomy alone (without a drainage procedure).