peptic ulcer

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peptic

 [pep´tik]
1. pertaining to pepsin.
2. pertaining to digestion by or other action of gastric juices.
peptic ulcer a loss of tissues lining the lower esophagus, stomach, or duodenum; an acute lesion that does not extend through the muscularis mucosae is simply called an erosion. Chronic ulcers involve the muscular coat, destroying the musculature and replacing it with permanent scar tissue at the site of healing.
Cause. While it is known that gastric hydrochloric acid and pepsin are responsible for ulcer formation, it is not known why mucosal resistance to them should become impaired. Duodenal ulcers and some prepyloric gastric ulcers are associated with an increased amount or hyperacidity of the gastric juice. Gastric ulcers, on the other hand, are not associated with excessive acid levels. Theories about genetic and environmental causes of peptic ulcer abound. Both gastric and duodenal ulcers tend to occur in families. Relatives of persons with gastric ulcers have three times the expected number of gastric ulcers. The same is true of duodenal ulcers. There is evidence that the increased familial incidence of both gastric and duodenal ulcers is not just due to a shared environment. An infection with Helicobacter pylori may contribute to ulceration, particularly in persons with a history of chronic gastritis.

Psychosomatic factors are known to play some role in the development of peptic ulcers. Psychologic stress can and does alter gastric function. Prolonged psychologic or physiologic stress produces what is known as a stress ulcer, which differs pathologically and clinically from a chronic peptic ulcer in being more acute and more likely to produce hemorrhage; perforation occurs occasionally and pain is rare. Conditions often associated with stress ulcers include severe trauma, surgery, advanced malignancy, extensive burns (Curling's ulcer), and brain injury.

Drug-induced ulcers are most commonly caused by the ingestion of aspirin, with alcohol running a close second. Other drugs that are strongly suspected of being ulcerogenic include the glucocorticoids, indomethacin, and phenylbutazone.
Symptoms. The cardinal symptom of peptic ulcer is epigastric pain that may be described as burning, gnawing, cramping, or aching, and usually comes in waves that last several minutes. The daily pattern of pain is related to the secretion of acid and the presence of food in the stomach to act as a buffer. This pain is diminished in the morning when secretion is low and after meals when food is present. The pain is most severe before meals and at bedtime. It often appears for three or four days or weeks and then subsides only to reappear weeks or months later. Other symptoms of uncomplicated peptic ulcer include nausea, loss of appetite, and sometimes weight loss.
Complications. The three major complications of ulcer are hemorrhage, perforation, and obstruction. Bleeding may be manifested by emesis of bright red blood or of coffee-ground vomitus, and by tarry feces. The bleeding may vary from massive hemorrhage to occult (hidden) bleeding that occurs over a period of time. Perforation frequently is a surgical emergency because of the possibility of a chemical peritonitis caused by spilling of the gastric and intestinal contents into the peritoneal cavity. Obstruction of the upper intestinal tract occurs as a result of scarring and loss of musculature at the pylorus. It is manifested by persistent vomiting that can quickly bring on alkalosis because of the loss of gastric acid in the vomitus. The obstruction is treated by surgical removal of the scar tissue.
Diagnosis. The most commonly used technique in the diagnosis of peptic ulcers is an upper gastrointestinal series with a barium test (barium swallow). Double contrast films are sometimes done to clearly define the mucosal pattern in the upper gastrointestinal tract. gastroscopy may be helpful in establishing the site of bleeding in a gastric ulcer, in differentiating between benign and malignant ulcerations based on biopsies, and between esophageal ulcer and diverticulum. Gastric analysis to determine level of acidity may be helpful in some cases but there is much individual variation in gastric acid secretions among patients with ulcer.
Treatment. The primary goals of medical treatment of peptic ulcers are: (1) relief of symptoms, (2) promotion of healing, (3) prevention of complications, and (4) prevention of recurrences. Because each patient responds differently to various modes of treatment, the medical regimen is planned according to individual needs and responses.

In general the medical management of ulcers hinges on antacids, drugs such as cimetidine that are antagonistic to histamine H2receptors, anticholinergic drugs, and sedatives; this is also accompanied by dietary modification and identifying and relieving sources of psychologic stress. Antacids such as magnesium hydroxide and aluminum hydroxide relieve the pain of ulcer by decreasing the levels of gastric hydrochloric acid and pepsin.

Cimetidine is an antagonist of histamine H2receptors and inhibits gastric acid secretion; it is easier to take than liquid antacids. It is an effective treatment for peptic ulcers but produces side effects in some patients, e.g., breast enlargement in men, mental confusion in elderly patients, and delayed hepatic metabolism of other drugs. sucralfate, which is not absorbed into the body, is an alternative drug that has fewer side effects and is also effective. Another drug, ranitidine, has action similar to that of cimetidine, but has greater potency, can be taken less frequently, and has fewer side effects.

If Helicobacter pylori is found in the ulcer, the patient is treated with antibiotics.

Most ulcers can be treated without surgery when patients cooperate fully; however, surgery may be necessary in certain cases, such as when there is scarring of the ulcer (producing obstruction), recurrent bleeding, extreme pain, and perforation. Gastric ulcers are more likely to require surgery than are duodenal ulcers. The operative procedure most frequently done for a gastric ulcer is subtotal gastrectomy, in which the ulcerous portion of the stomach is removed (see also surgery of the stomach). This procedure is often done in conjunction with vagotomy, division of the vagus nerve, which eliminates cerebral stimuli of the stomach muscle and glands, thereby reducing gastric motility and secretion.
Patient Care. Assessment data pertinent to peptic ulcer patients include information about (1) family history of peptic ulcer, (2) the patient's eating habits and how eating affects symptoms, (3) whether the patient drinks or smokes and to what extent, (4) any history of psychological or physical stress such as severe trauma, burns, or other conditions that might produce a stress ulcer, and (5) any drugs the patient might be taking that are irritants to the gastrointestinal tract.

Dietary restrictions are usually limited to those foods, if any, that an individual identifies with the onset or worsening of symptoms. Exceptions are alcohol and caffeine, both of which are capable of inducing gastritis and promoting erosion of the gastric mucosa. It is generally agreed that what the patient with an ulcer eats is not as important as when it is eaten. Frequent and regular feedings throughout the day, rather than two or three large meals, are encouraged. Patients should not skip meals and should try to have some nonirritating food in the stomach at all times.

Patient education includes the following: (1) Regulate the types of foods eaten and the manner in which they are eaten. Meals should be unhurried, relaxed, and spaced at regular intervals. (2) Try to avoid situations of stress and anxiety and develop some effective skills for coping with stress. (3) Drink water at least once every hour when awake. This acts to dilute gastric juices, making them less corrosive. (4) Stop or at least cut down on smoking. (5) Keep alcohol intake to a minimum. (6) Report any side effects of antacids or other drugs to the health care provider. There are alternative drugs if the side effects of one are worrisome. (7) Take prescribed medications exactly as ordered and do not discontinue them without consulting the health care provider. (8) Avoid taking aspirin; develop the habit of reading labels of nonprescription drugs to ascertain whether they contain acetylsalicylic acid. Since some prescription drugs also contain aspirin, inform any health care provider treating a coexisting condition that aspirin cannot be tolerated.
Peptic ulcer. A, Gross appearance of the ulcer as seen by endoscopy. B, Histologically, the bottom of the ulcer replacing the mucosa consists mostly of granulation tissue and admixed necrotic cell debris and inflammatory cells. Peptic ulcer may bleed from eroded mucosa blood vessels. The tissue underlying the ulcer shows fibrosis and scarring. From Damjanov, 2000.
Most common sites for peptic ulcer disease. From Frazier et al., 2000.

ulcer

 [ul´ser]
a local defect, or excavation of the surface of an organ or tissue, produced by sloughing of necrotic inflammatory tissue.
aphthous ulcer a small painful ulcer in the mouth, approximately 2 to 5 mm in diameter. It usually remains for five to seven days and heals within two weeks with no scarring.
chronic leg ulcer ulceration of the lower leg caused by peripheral vascular disease involving either arteries and arterioles or veins and venules of the affected limb. Arterial and venous ulcers are quite different and require different modes of treatment. Venous stasis ulcers occur as a result of venous insufficiency in the lower limb. The insufficiency is due to deep vein thrombosis and failure of the one-way valves that act during muscle contraction to prevent the backflow of blood. Chronic varicosities of the veins can also cause venous stasis.

Patient Care. Stasis ulcers are difficult to treat because impaired blood flow interferes with the normal healing process and prolongs repair. Patient care is concerned with preventing a superimposed infection in the ulcer, increasing blood flow in the deeper veins, and decreasing pressure within the superficial veins.
decubitus ulcer pressure ulcer.
duodenal ulcer an ulcer of the duodenum, one of the two most common types of peptic ulcer.
gastric ulcer an ulcer of the inner wall of the stomach, one of the two most common kinds of peptic ulcer.
Hunner's ulcer one involving all layers of the bladder wall, seen in interstitial cystitis.
hypertensive ischemic ulcer a manifestation of infarction of the skin due to arteriolar occlusion as part of a longstanding vascular disease, seen especially in women in late middle age, and presenting as a red painful plaque on the lower limb or ankle that later breaks down into a superficial ulcer surrounded by a zone of purpuric erythema.
marginal ulcer a peptic ulcer occurring at the margin of a surgical anastomosis of the stomach and small intestine or duodenum. Marginal ulcers are a frequent complication of surgical treatment for peptic ulcer; they are difficult to control medically and often require further surgery.
peptic ulcer see peptic ulcer.
perforating ulcer one that involves the entire thickness of an organ, creating an opening on both surfaces.
phagedenic ulcer
1. any of a group of conditions due to secondary bacterial invasion of a preexisting cutaneous lesion or the intact skin of an individual with impaired resistance as a result of a systemic disease, which is characterized by necrotic ulceration associated with prominent tissue destruction.
pressure ulcer see pressure ulcer.
rodent ulcer ulcerating basal cell carcinoma of the skin.
stasis ulcer ulceration on the ankle due to venous insufficiency and venous stasis.
stress ulcer a type of peptic ulcer, usually gastric, resulting from stress; possible predisposing factors include changes in the microcirculation of the gastric mucosa, increased permeability of the gastric mucosa barrier to H+, and impaired cell proliferation.
trophic ulcer one due to imperfect nutrition of the part.
tropical ulcer
1. a lesion of cutaneous leishmaniasis.
tropical phagedenic ulcer a chronic, painful phagedenic ulcer usually seen on the lower limbs of malnourished children in the tropics; the etiology is unknown, but spirochetes, fusiform bacilli, and other bacteria are often present in the developing lesion, and protein and vitamin deficiency with lowered resistance to infection may play a role in the etiology.
varicose ulcer an ulcer due to varicose veins.
venereal ulcer a nonspecific term referring to the formation of ulcers resembling chancre or chancroid about the external genitalia; there are both sexually transmitted and other types.

pep·tic ul·cer

an ulcer of the alimentary mucosa, usually in the stomach or duodenum, exposed to acid gastric secretion.

peptic ulcer

a sharply circumscribed loss of the mucous membrane of the stomach, duodenum, or any other part of the GI system exposed to gastric juices containing acid and pepsin. Also called gastric ulcer.
observations Peptic ulcers may be acute or chronic. Acute lesions are almost always multiple and superficial. They may be totally asymptomatic and usually heal without scarring or other sequelae. Chronic ulcers are true ulcers. They are deep, single, persistent, and symptomatic; the muscular coat of the wall of the organ does not regenerate; a scar forms, marking the site, and the mucosa may heal completely. Peptic ulcers are caused by a combination of poorly understood factors, including an excessive secretion of gastric acid, inadequate protection of the mucous membrane, stress, heredity, and the use of certain drugs, including the corticosteroids, certain antihypertensives, and antiinflammatory medications (especially acetylsalicylic acid and nonsteroidal antiinflammatory drugs). There is growing evidence from research that a bacterium present in the gut-Helicobacter pylori-may be responsible for peptic ulcer disease. Characteristically ulcers cause a gnawing pain in the epigastrium that does not radiate to the back, is not aggravated by a change in position, and has a temporal pattern that mimics the diurnal rhythm of gastric acidity.
interventions Symptomatic relief is provided with drugs that either neutralize or block secretion of acid and frequent small bland meals. The underlying cause is treated if known. If H. pylori is present, a 2-week triple therapy regimen of tetracycline, metronidazole, and bismuth may be given. Hemorrhage caused by perforation of the muscle and blood vessels may require surgical resection of the damaged area. The diagnosis and evaluation of peptic ulcers involve serial radiographic studies using a contrast medium and endoscopy. A definitive diagnosis is important because the early signs of cancer of the stomach and duodenum resemble those of peptic ulcers.
nursing considerations The patient is reassured that in most cases the ulcers heal completely and that the pain may be controlled with simple measures. The nurse emphasizes the correct use of antacids and the other medications prescribed. Usually the patient is instructed to eat frequent small meals consisting of foods known to be nonirritating. For many but not all patients, fatty, highly spiced, heavy, or fibrous foods are likely to provoke pain. The use of tobacco and alcohol is discouraged.
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Peptic ulcer

pep·tic ul·cer

(pep'tik ŭl'sĕr)
An ulcer of the alimentary mucosa, usually in the stomach or duodenum, which has been exposed to acid gastric secretion.

peptic ulcer

An area on the inner mucosal surface of the STOMACH, DUODENUM or OESOPHAGUS in which stomach acid and digestive ENZYMES have acted to as to erode the surface and expose the underlying layers of muscle. Infection with Helicobacter pylori organisms is important, especially in the case of duodenal ulcer. In extreme cases perforation occurs. Peptic ulcers are treated by eradication of H. pylori with METRONIZADOLE or clarithromycin and the use of proton pump inhibitor drugs such as OMEPRAZOLE or HISTAMINE receptor blocker drugs such as CIMETIDINE or RANITIDINE (Zantac) which reduce acid production. Sometimes a protective drug such as sucralfate may be used. See also ZOLLINGER-ELLISON SYNDROME.

Peptic ulcer

Ulcers in the stomach and upper duodenum (first portion of the small intestine) caused by stomach acid and a bacterium called Helicobacter pylori.

pep·tic ul·cer

(pep'tik ŭl'sĕr)
A lesion of the alimentary mucosa or which has been exposed to acid gastric secretion.

peptic

pertaining to pepsin or to digestion or to the action of gastric juices.

peptic ulcer
an ulceration of the mucous membrane of the esophagus, stomach or duodenum, caused by the action of the acid gastric juice. There are two kinds of peptic ulcers: gastric ulcers occur in the stomach; duodenal ulcers occur in the duodenum, the part of the small intestine nearest the stomach. Most common in cattle and dogs, but they do occur sporadically in other species. See also zollinger-ellison syndrome.