Peptic ulcer is a common condition. Ten per cent of the population suffers from it at some time or another. The incidence and severity of peptic ulcer disease are decreasing in the Western world but they are increasing in developing countries. Because of the widespread use of non-steroidal anti-inflammatory drugs (NSAID), the incidence of ulcer disease in the elderly is increasing.
The cardinal symptom of duodenal ulcer is pain. The pain is typically localized to the epigastria, is dull or burning in character, starts several hours after a meal, wakes the patient at night and is relieved by food or antacids. Nausea and vomiting may be present during acute exacerbation but are not prominent features. In contrast to patients with non-ulcer dyspepsia, ulcer patients localize the pain to the epigastrium with one finger. Apart from mild tenderness in the epigastrium, patients with uncomplicated ulcer disease do not have physical signs. The course of duodenal ulcer disease is one of relapses an reissions. The patient complains of episodes of severe pain lasting for weeks interspersed by months of remission, the pattern repeating itself over several years. The disease may burn itself out after 10-15 years.
It is difficult to differentiate duodenal ulcer from other causes of dyspepsia (gastric ulcer, non-ulcer dyspepsia, reflux oesophagitis, gastric cancer, gallstone) with confidence on clinical grounds alone. Barium meal may show an ulcer crater. However, it may be difficult to differentiate active ulceration from scarring. Flexible endoscopy is the most accurate diagnostic method. The oesophagus, stomach and the first and second part of the duodenum can be clearly seen using this technique.
The aim of treatment is to alleviate the ulcer pain, to heal the ulcer, to prevent recurrence and to forestall complications.With powerful anti-secretory drugs and effective regimens to eradicate Helicobacter, these aims can be achieved by medical therapy in the great majority of patients. Apart from giving up smoking and avoiding, if possible, ulcerogenic drugs, lifestyle modification such as a change in diet or avoidance of stress is not necessary. Such changes are difficult to make and there is little evidence that they accelerate ulcer healing. Nowadays, elective surgery for uncomplicated ulcer disease is rarely, if ever, indicated. Nearly all ulcer surgery is performed as an emergency procedure for complications.
Gastric ulcers are less common than duodenal ulcers. They affect the older age group. Gastric ulcers are more common in patients from lower socioeconomic groups.
Non-steroidal anti-inflammatory drugs are a common cause of gastric ulcers.
As in duodenal ulceration the usual presentation is epigastric pain. The pain is typically exacerbated by food; nausea, unremitting pain and weight loss are common. Differentiation from duodenal ulcer (and gastric cancer) is unreliable.
In double-contrast barium meal examination the stomach wall is coated with a thin layer of barium and effervescent drink is given to distend the stomach with gas. Benign gastric ulcers appear as craters, penetrating beyond the expected stomach contour, with mucosal
folds radiating from the ulcer like spokes of a wheel. Irregular ulcer edges, a crater protruding into the lumen of the stomach, irregular mucosal folds with no peristalsis, and ulcers located at sites other than the lesser curvature and the antrum, suggest malignancy.
All demonstrated gastric ulcers must be investigated by endoscopy and biopsy.
Through the endoscope a benign gastric ulcer has smooth, regular margins. The most common site is the angular incisura, followed by the lesser curvature and the antrum. An ulcer seen outside these locations should be presumed malignant. Malignant ulcers are
irregular with raised, rolled-up edges. With potent acid suppression, even malignant ulcers may completely heal over temporarily, leaving an area of mucosal irregularity.
All gastric ulcers must have multiple biopsies taken from all four quadrants of the ulcer. After a course of therapy, repeat endoscopy to assess healing and repeat biopsy are mandatory.
Although acid output is normal or low in patients with gastric ulcers, ulcer pain is controlled and the ulcer heals with acid suppression. H2 blockers or omeprazole
may be used. Because gastric ulcers are larger than duodenal ulcers they generally take longer to heal. Some 70% of gastric ulcers are associated with H.pylori. Eradication of the bacteria is indicated in such patients to reduce the recurrence rate. Other gastric ulcers
are caused by NSAID. If it is not possible for the patient to stop taking NSAID, a proton pump inhibitor taken concurrently confers a degree of protection. Gastric cancer may masquerade as a gastric ulcer. If complete healing of the ulcer is not achieved with two
or three courses of medical therapy, surgical resection of the ulcer is indicated.
The aim of surgical treatment is to resect the ulcer bearing part of the stomach. The operation of choice for gastric ulcers is Billroth I gastrectomy, in which the
distal half of the stomach is removed and gastro duodenal continuity restored. In elderly, frail patients, and in those with an ulcer high on the lesser curvature where
resection would entail removal of most of the stomach, excision of the ulcer with vagotomy and pyloroplasty may be an alternative.