Peptic ulcer

Signs and symptoms

Patients presenting with peptic ulcer disease will most usually present with abdominal pain. This mainly will be in the epigastric region (the upper abdominal region) without any radiation. The pain is usually described as dull ache or burning sensation. Other symptoms that patients will complain about are nausea, loss of appetite, diarrhoea, and weight loss. In addition, they may experience vomiting, and this sometimes may be haematemesis. Those with long-term dyspepsia, symptoms such as heartburn, belching, fullness, and a history of gastro-oesophageal reflux disease can be vulnerable to peptic ulcer disease. There are no particular signs on physical examination however epigastric tenderness can be elicited on abdominal palpation.

ALARM Symptoms include:

• Anaemia
• Loss of weight
• Anorexia
• Recent onset of progressive symptoms
• Melaena/Haematemesis
• Swallowing difficulty

These symptoms are important to investigate as stomach cancer could present like this.

Causes

Peptic ulcers can be caused by a bacteria Helicobacter pylori (H pylori). Interestingly in 2005 a Nobel prize was awarded to Barry J. Marshall and J. Robin Warren for their discovery of "the bacterium Helicobacter pylori and its role in gastritis and peptic ulcer disease”. In addition to H pylori, non-steroidal anti-inflammatory drugs (NSAIDs) contribute to ulcer formation, as well as aspirin, alcohol, and other less common causes are things like caffeine, tobacco smoking, radiation therapy, physical stress due to illness, Crohn's disease, liver disease and in addition to these, Zollinger-Ellison syndrome is a risk factor too. This is a gastrin secreting tumour of the pancreas leading to increased acid production in the stomach.

Diagnosis

Diagnosis can be made clinically, however for confirmation of diagnosis, investigations such as oesophago-gastro-duodenoscopy (OGD) and barium swallow abdominal x-rays can be carried out. Endoscopy is diagnostic test for peptic ulcer disease. If the patient is above the age of 45 with any of the alarm symptoms present or if symptoms do not resolve after a few weeks of treatment it is essential to investigate with endoscopy.

Full blood count needs to be checked for signs of microcytic anaemia.

When testing for H Pylori, the urea breath test is the gold standard for detecting H pylori because it is a rapid and non-invasive diagnostic technique. Blood tests to measure antibodies and stool antigen test can also be useful. A stool heme test is also an option to check for occult blood, this is usually negative. The CLO test (campylobacter like organism) is a biopsy test which detects the presence of H. Pylori in the stomach and duodenum. A biopsy is taken from the gastric antrum, and the tissue is placed onto a urea containing mediator. If H. Pylori is present, the indicator changes colour, as the urease produced by the bacteria converts the urea to ammonia, and hence the medium becomes more alkaline (the change is from yellow to red).

Management

Lifestyle changes are important to advise to the patients of peptic ulcer, such as avoiding drinking alcohol and medications like aspirin and NSAIDS, to quit smoking is also essential.

Medical therapy includes acid reducing medication such as H2 antagonists (examples are ranitidine, cimetidine and famotidine) or proton pump inhibitor’s (examples are omeprazole, lansoprazole and rabeprazole) which can be taken for four weeks.

In the case where H pylori is present, the most effective treatment for this is called triple therapy. This is a combination of two antibiotics such as Clarithromycin and Amoxicillin, (Amoxicillin can be replaced with Metronidazole for those allergic to penicillin) and a proton pump inhibitor such as Omeprazole.

Endoscopy is required for bleeding peptic ulcers, where cautery or clipping is used to stop the bleed. Emergency surgery is used for a perforated peptic ulcer. This requires urgent repair of the perforation.

For follow up those treated for gastric ulcer disease will need an endoscopy six to eight weeks after treatment was initiated. Those with H Pylori need to be checked four weeks after the end of their treatment regime.