PEPTIC ULCER- RUINOUS CAUSE AND STRATEGY OF CESSATION

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R. Gowri et al. World Journal of Pharmacy and Pharmaceutical Sciences

PEPTIC ULCER- RUINOUS CAUSE AND STRATEGY OF

CESSATION

R. Gowri*, N. Narayanan, A. Maheswaran, G. Harshapriya, Siji Mathachan,

B. Karthick

Jaya College of Pharmacy, Thiruninravur, India.

ABSTRACT

The English word "peptic" comes from the Greek word peptein,

meaning "to digest". The English word "ulcer" comes from the Latin

word ulcus (genitive: ulceris), meaning "a sore, a wound, an ulcer.

Peptic ulcer represents a chronic gastrointestinal illness poses serious

medical problem. For the past twenty years Peptic ulcers can be seen

as an area in which the development of new medicines especially

more successful in improving outcomes. A crater like sore or wound is

called ulcer. Stomach acids such as hydrochloric acid and pepsin are present in peptic ulcers.

However, Peptic ulcer means an ulcer in the digestive system of the stomach (duodenum,

esophagus). Peptic ulcer is a sore in mucosal lining of the stomach (gastric ulcer) or the first

part of the small intestine (duodenal ulcer) a due to result of acid and pepsin effect in the

lumen marked by tissue disintegration. No single cause has been found for ulcers. However,

it occurs due to imbalance between digestive fluids in the stomach and duodenum. Peptic

ulcer are benign but do not change the normal functions of stomach but it may cause

bleeding and pain. Historically it was believed lifestyle factors, such as stress and diet caused

ulcers. Later, researches reveals that stomach acid such as hydrochloric acid and pepsin are

the reasons to peptic ulcer due to . infection with a bacterium called Helicobacter pylori (H.

pylori). To any age group people ulcers can appear but duodenal ulcers frequently occurs in

patients between the ages of 30 – 55 yrs. Peptic ulcers persist to smokers and NSAIDs taking

patients.If untreated it may leads to a bleeding and perforated ulcer. Injury to gastric mucosal

lining and mucous defence weakness plays important role for gastric ulcers. The symptoms

are gnawing pain, nausea, loss of appetite, weight loss and weakness. Medication can be

used to treat stomach ulcers. proton pump inhibitor can usually reduce the amount of acid in

our digestive system for healing ulcer. Combination therapy with antibiotics is given If an H.

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Article Received on 25 March 2014, Revised on 15 April 2014, Accepted on 07May 2014

*Correspondence for Author

R. Gowri

Jaya College of Pharmacy,

Thiruninravur, India.


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pylori infection is responsible for the ulcer. The diagnosis of an ulcer is made by either a

barium upper gastrointestinal X-ray (upper GI series) or an upper gastrointestinal endoscopy.

This review focusses on pathophysiology of peptic ulcer along with recent approaches in

curing it.

INTRODUCTION

Ulcer is the most common cause of massive upper gastrointestinal haemorrhage. Peptic ulcer

is a distinct breach in the stomach mucosal lining (gastric ulcer) or the first part of the small

intestine (duodenal ulcer) due to acid and pepsin in the lumen.1 It poses serious problem with

abdominal pain. Peptic ulcers include:

Gastric ulcers that occur on the inside of the stomach

Esophageal ulcers that occur inside the hollow tube (esophagus) which carries food from

throat to stomach

Duodenal ulcers that occur on the inside of the upper portion of small intestine

(duodenum)2

Anatomy and function of Stomach

The body utilising number of defense mechanisms protect the stomach from the acid it

produces. Any agents or conditions that decrease these normal defense mechanisms can

predispose the formation of ulcer in the stomach. The lining of cells produce gastric acid

along with mucus creating a viscous barrier to control the stomach damage from gastric acid3

Approximately parietal cells in stomach secrete two litres of hydrochloric acid which helps

in food digestion.

The acid is essential to maintain pH between 1.8 – 3.5 for efficient function of pepsin, a

digestive enzyme. The stomach epithelium resist to gastric acid damaging effects. 4

Compared to HCL the secretion of mucus and bicarbonate are at higher rate affords

protection by slowing its diffusion towards lining and neutralising the acid before it reaches

stomach. However if either HCL is increased or bicarbonate decreased to damage the cells

of stomach occurs.5


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Fig 1 : Peptic ulcer

Helicobacter pylori ( H. pylori), earlier called Campylobacter pylori,found in stomach is

a gram-negative microaerophilic bacterium in nature is a major cause of peptic ulcers H.

pylori is found in the mucus, on the inner surface of the epithelium, and occasionally inside

the epithelial cells themselves occasionally6. When H. pylori colonizes other areas of the

stomach induce chronic gastritis, the inflammatory response can result in atrophy of the

stomach lining and eventually ulcers in the stomach. This also may leads to stomach cancer

also. If normal or reduced amounts of acid secreted H. pylori can also colonize the rest of

the stomach.7

Fig 2 : Helicobacter pylori

Classification of peptic ulcer

Type I: Ulcer along the lesser curve of stomach

Type II: Two ulcers present - one gastric, one duodenal/prepyloric

Type III: Prepyloric ulcer

Type IV: Proximal gastroesophageal ulcer

Type V: Anywhere in stomach8


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Symptoms

Gnawing pain (felt from navel up to breastbone)

o Causes awakening from sleep

o May last for a few minutes or several hours

o Feels like unusually strong hunger pangs

o May be relieved by taking antacids

Nausea

Vomiting

Bloating

Heartburn

Appetite changes

Bloating

Burping

Weight loss

Weakness

Fatigue

Lightheadedness

Dark blood in stools that are black or tarry9-10

Alarm symptoms

Bleeding occurs when acid or the peptic ulcer breaks a blood vessel

Perforation occurs when the peptic ulcer burrows completely through the stomach or

duodenal wall

Obstruction occurs when the peptic ulcer blocks the path of food trying to leave the

stomach11

Risk factors of Peptic ulcer

Smoking

Smoking interferes with the protective lining of the stomach making it susceptible to ulcer

development. Smoking also decreases factors that protect or heal the lining like mucus

secretion ,clear liquid that protects the lining from acid and sodium bicarbonate production

that neutralizes acid. 12


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Alcohol consumption

Excessive consumption of alcohol have higher risk of developing peptic ulcers with erosion

of mucosal lining of stomach occurs. People with cirrhosis alcohol trigger to cause gastric

wounds lining in stomach which may interfere with normal healing process of ulcers13

NSAIDs (non-steroidal anti-inflammatory drugs)

NSAIDs are medicines that reduce pain, fever, and inflammation. These medications can

irritate or inflame the lining of stomach and small intestine.Examples include aspirin and

ibuprofen( OTC medications), diclofenac, naproxen and meloxicam ( doctor's prescription ).

It make the stomach vulnerable to the harmful effects of acid and pepsin. . Even safely

coated aspirin can frequently cause ulcers. The use of multiple NSAIDs and longer intake

of NSAIDs also contribute to ulcer. It affects the blood flow to stomach also.14

Mental stress

Modern life presents stressful situations to us on a daily basis. This constant stress disturbs

the secretion of stomach acids and pepsin, an enzyme produced in the stomach that splits

proteins into peptones. 15

Diagnosis of Peptic ulcer

The diagnosis of an ulcer is done by

Gastroscopy or endoscopy

Biopsy

Barium x-rays

Gastroscopy (Esophagogastroduodenoscopy (EGD, upper endoscopy)

It is a special test performed by a gastroenterologist involves sedation of the patient by

insertion of a flexible tube through the mouth to inspect the esophagus, stomach, and

duodenum. By gastroscope samples or photographs of the mucous membrane are taken.

The most modern gastroscopes reveals the areas in the stomach on a TV screen, which

enhances the study of mucous membrane thoroughly. This can be recorded on a videotape,

and used for later comparison. The goal of endoscopic therapy is to "seal" the blood vessel

involved and stop the bleeding. This may be accomplished in a variety of ways and several

endoscopic methods of treatment rely on heat like laser, electrocoagulation and heat probe.


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Fig 3: Upper endoscopy

. Biopsy

A biopsy (a small piece of the lining of the stomach) may be removed during an endoscopy

and examined under the microscope in the laboratory to pinpoint an infection and observed

for any other abnormality. In combination with a biopsy, endoscopy is the most accurate

procedure for detecting the presence of peptic ulcers, bleeding, and stomach cancer, or for

confirming the presence of H. pylori.

Upper GI series (Barium X-rays)

It was the standard method for diagnosing peptic ulcers until endoscopy and tests for

detecting H. pylori were introduced. Upper GI is a series of x-rays taken after the patient

drink a thick substance called barium. X-rays are then taken, which may reveal inflammation,

active ulcer craters, or deformities and scarring due to previous ulcers. This technique is also

known as a Barium Swallow. It is an examination of the esophagus and stomach with aid of

barium solution . Barium coat the walls of the upper digestive tract for x- ray examination.

Barium swallows are used to identify ulcers, and to detect any abnormalities of the upper

gastrointestinal tract such as tumors, hernias, pouches, swallowing difficulties. 16-18

Diagnostic tests for H. pylori

Helicobacter pylori tests are used to detect Helicobacter pylori infection in the stomach and

upper part of the small intestine


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The choice of test depends upon issues such as cost, availability, clinical situation, population

prevalence of infection, and factors such as the use of proton pump inhibitors and antibiotics

that may influence certain test results.

Breath test

Blood test

Stool test

Breath test (Breath Test (Carbon Isotope-urea Breath Test, or UBT)

A urea breath test is used to detect H. pylori bacteria in stomach and reveals the patient is

infected or not with H. pylori . Certain precautions to be followed are

Up to 2 weeks before the test antibiotics intake , bismuth medicines such as Pepto-

Bismol, and proton pump inhibitors (PPIs) should be stopped

During a breath test, patient swallow a pill, liquid or pudding that contains radioactive

carbon molecules. If H. pylori infection present the radioactive carbon is released when

the solution is broken down in stomach. The body absorbs the radioactive carbon and

expels it exhale. Exhalation done into a bag uses a special device to detect the

radioactive carbon.

During the test, special substance urea has to be swallowed . Urea is a waste product the

body produces as it breaks down protein. The urea used in the test has been made

harmlessly radioactive.

Blood tests

It is used to measure antibodies to H pylori. Antibodies are proteins made by the body’s

immune system when it detects harmful substances such as bacteria. Analysis of a blood

sample may reveal evidence of an active or previous H. pylori infection in your body. A

blood sample is usually collected by pricking the finger. If antibodies of H. pylori present

in blood, it indicates patient is currently infected or previously have been infected

Enzyme linked immunosorbent assay (ELISA). An ELISA test of the urine is used for

diagnosing H. pylori in children.

Stool Test

A laboratory test called a stool antigen test looks for foreign proteins (antigens)

associated with H. pylori infection in stool.

A stool test can detect traces of H pylori in the feces.


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It is a test to detect genetic fingerprints of H pylori in feces.

This test can be used to diagnose the infection and confirm that it has been cured after

treatment.19-20

Peptic ulcers consequences

If left untreated the following conditions may occur.

Bleeding ulcers

It is a serious condition and a blood transfusion is often required.

Treatment with NSAIDs and aspirin should be discontinued immediately.

A gastroscopy is done to analyse the cause of bleeding

estimate the risk of new bleeds

inject a substance into the mucosa lining the gut adjacent to the ulcer to minimise the

chance of a significant recurrence of bleeding

In certain cases it causes anaemia also.

Perforated ulcer

A perforated ulcer is a serious condition that needs emergency attention.

An X-ray of the chest and abdomen taken to check whether air has escaped through the

perforation and then risen to underneath the diaphragm.

A perforated ulcer requires emergency surgery to close the hole and prevent stomach

contents leaking further into the abdominal cavities. This leakage leads to infection.

Fig 4: Perforated ulcer

Scar tissue

Peptic ulcers also produce scar tissue which block passage of food in the digestive tract,

causing to vomit and to lose weight.21


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Treatment for Peptic ulcer

The goal of ulcer treatment is to relieve pain, heal the ulcer, and prevent complications. The

first step in treatment involves the reduction of risk factors (NSAIDs and cigarettes). The

next step is medications. It if involves the use of antacids, antibiotics, H2 blockers, Proton

pump inhibitors

Antacids: Antacids neutralize existing stomach acid and can provide rapid pain relief.

Antacids such as aluminum hydroxide, calcium carbonate, and magnesium hydroxide or

magnesium carbonate make stomach juices less acidic. Simethicone may help relieve gas

symptoms.

Antibiotics: It kill Helicobacter pylori (H. pylori) bacteria if they are present.

Proton pump inhibitors It reduces stomach acid by blocking the action of the parts of

cells that produce acid. These drugs include the prescription and over-the-counter

medications omeprazole , lansoprazole, rabeprazole etc.

H2 blockers. These reduce the amount of acid production in stomach . Ex Famotidine,

Ranitidine etc.22-24

Surgical treatment

There are surgeries to repair the damage done by ulcers in the stomach lining. When surgery

is done, it usually involves one or more of the following:

Cutting one or more of the nerves to the stomach (vagotomy).

Widening the opening of the bottom of the stomach (pyloroplasty).

Removing part of the stomach (partial gastrectomy).25

Miscellaneous methods

1. Lifestyle Changes: Maintaining a healthy diet and limiting stress can help the stomach to

not over produce acid. Daily exercise and proper water intake make the stomach contents

empty properly.

2. Control stress. Stress may worsen the signs and symptoms of a peptic ulcer. Hence proper

control over stress is very essential.

3. Quit smoking Smoking may interfere with normal stomach functions thereby smoking

has to be avoided completely.

4.Limit or avoid alcohol. Excessive use of alcohol cause irritation and erosion to the

mucous in stomach.


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5.Choose a healthy diet.A healthy diet full of fruits, vegetables and whole grains has to be

followed .

6.Citruses and their juices: Citrus fruits, such as lemons, oranges, grapefruits, and limes are

higher in acidity than other fruits. Hence, it is better to avoid acidic fruits to reduce the risk of

irritation.

Fig 5: Healthy diet for peptic ulcer

The following are some foods that has to be avoided

1. Beverages

a. Hot cocoa and cola

b. Whole milk and chocolate milk

c. Peppermint and spearmint tea

2. Spices and seasonings

a. Black and red pepper

b. Garlic powder

c. Chili powder

3. Other foods

a. Spicy or strongly flavored cheeses, black pepper

b. Highly seasoned, high-fat meats.

Healthy diet for peptic ulcer patients

Generally, dietary fiber is more important in maintaining optimal gastrointestinal health and

help to the recovery of peptic ulcers. Some foods high in fiber include:

Fresh fruits and vegetables

Whole grain breads

Oatmeal


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Barley

Popcorn without butter or additives26- 28

CONCLUSION

Ulcer disease are one of the major cause of recurrent ill health with many relapses and

which required long-standing medical treatment. Peptic ulcer disease (PUD) refers to a

disruption of the mucosal integrity of the stomach, duodenum, or both caused by local

inflammation, which leads to a well-defined mucosal defect . Efficient treatment with

medications and successful Helicobacter pylori eradication result in clinical improvement

and cure as well as in long-term healing of ulcers. Today, research reports reveals that most

ulcers develop as a result of infection with bacteria called Helicobacter pylori (H. pylori).

While all three of these factors--lifestyle, acid and pepsin, and H. pylori--play a role in ulcer

development, H. pylori is now considered as the primary cause. Many ulcer research studies

are ongoing with the aim to minimise the risk of peptic ulcer disease.

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PEPTIC ULCER- RUINOUS CAUSE AND STRATEGY OF CESSATION

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