Gastric Ulcers

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Author

Sanjeeb Shrestha, MD, Consulting Staff, Division of Gastroenterology, North West Arkansas Gastroenterology Clinic

Nothing to disclose.

Coauthor(s)

Daryl Lau, MD, MPH, FRCP(C), Director of Translational Liver Research, Beth Israel Deaconess Medical Center; Associate Professor of Medicine, Harvard Medical School

Nothing to disclose.

Specialty Editor(s)

Alex J Mechaber, MD, FACP, Associate Dean for Undergraduate Medical Education, Associate Professor of Medicine, University of Miami Miller School of Medicine

Nothing to disclose.

David Greenwald, MD, Fellowship Program Director, Associate Professor, Department of Medicine, Division of Gastroenterology, Montefiore Medical Center, Albert Einstein College of Medicine

Nothing to disclose.

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine

eMedicine Salary Employment

Simmy Bank, MD, Chair, Professor, Department of Internal Medicine, Division of Gastroenterology, Long Island Jewish Hospital, Albert Einstein College of Medicine

Nothing to disclose.

Chief Editor

Julian Katz, MD, Clinical Professor of Medicine, Drexel University College of Medicine; Consulting Staff, Department of Medicine, Section of Gastroenterology and Hepatology, Hospital of the Medical College of Pennsylvania

Nothing to disclose.

Background

Peptic ulcer disease (PUD) is one of the most common diseases affecting the gastrointestinal (GI) tract. It causes inflammatory injuries in the gastric or duodenal mucosa, with extension beyond the submucosa into the muscularis mucosa. The etiologies of this condition are multifactorial and are rarely related simply to excessive acid secretion. Even though gastric ulcer is a common disease, a diagnosis can be difficult because it has a wide spectrum of clinical presentations, ranging from asymptomatic to vague epigastric pain, nausea, and iron-deficiency anemia to acute life-threatening hemorrhage.


View Image

Gastric ulcer with punched-out ulcer base with whitish fibrinoid exudates.


View Image

Gastric ulcer (lesser curvature) with punched-out ulcer base with whitish exudate.

Pathophysiology

The normal stomach maintains a balance between protective factors, such as mucus and bicarbonate secretion, and aggressive factors, such as acid secretion and pepsin. Gastric ulcers develop when aggressive factors overcome protective mechanisms.

The two major etiological factors for PUD are Helicobacter pylori infection and nonsteroidal anti-inflammatory drug (NSAID) consumption. Currently, 70% of all gastric ulcers occurring in the United States can be attributed to H pylori infection. In addition to an increase in acid secretion, H pylori infection also predisposes patients to ulcer disease by disrupting mucosal integrity. The bacterium's spiral shape and flagella facilitate its penetration into the mucous layer and its attachment to the epithelial layer. Subsequently, it releases phospholipase and proteases, which cause further mucosal damage. A cytotoxin-associated gene (cag A) has been isolated in approximately 65% of the bacteria. The products of this gene are associated with more severe gastritis, gastric ulcer, gastric cancer, and lymphoma.

Cigarette smoking can affect gastric mucosal defense adversely. Cigarette smoking is believed to play a facultative role in H pylori infection. People who smoke tend to develop more frequent and recurrent ulcers and their ulcers are more resistant to therapy. No evidence indicates that dietary habits or alcohol consumption predisposes individuals to gastric ulcer.

NSAID-induced ulcers account for approximately 26% of gastric ulcers, and they are believed to be secondary to a decrease in prostaglandin production resulting from the inhibition of cyclooxygenase.[1] The topical effects of NSAIDs are superficial gastric erosions and petechial lesions. However, the risk of gastroduodenal ulcer is not diminished with parental or rectal use of NSAIDs indicating injury occurring from the systemic effect of NSAIDs on the gastrointestinal mucosa. The greatest risk of developing an ulcer occurs during the first 3 months of NSAID use; thereafter, the risk decreases but continues to be present. Whether concurrent H pylori infection and NSAID use are synergistic in producing gastric ulcers remains unclear. Recent accumulating evidence indicates that patients with H pylori infection may be twice as likely to get a bleeding peptic ulcer.

Selective COX-2 (cyclooxygenase) inhibitors, like celecoxib (Celebrex), rofecoxib (Vioxx), and valdecoxib (Bextra), have been shown to cause gastroduodenal ulcers at a rate comparable to placebo (4%). In the Celecoxib Long-term Arthritis Safety Study (CLASS), they found a significantly lower incidence of symptomatic ulcers in patients taking celecoxib for the initial 6 months as compared to patients taking ibuprofen or diclofenac. Currently, the only US Food and Drug Administration (FDA)-approved COX-2 inhibitor available is celecoxib, as rofecoxib and valdecoxib were withdrawn from the market by the FDA because of increased cardiovascular risk.

Other medications that predispose patients to gastroduodenal ulcers include potassium chloride, chemotherapeutic agents, and bisphosphonates.

A rare cause of PUD is Zollinger-Ellison syndrome (ie, gastrinoma). The hallmark of Zollinger-Ellison syndrome is the profound hypersecretion of gastric acid. Significant disruption of the mucosal integrity often results in multiple duodenal and gastric ulcers.

Epidemiology

Frequency

United States

The annual incidence of gastric ulcer is largely determined from the statistics of the pre– H pylori era (prior to 1979). It is estimated to affect 0.92% of the population or 1.6 million persons. Epidemiological studies show that from 1970-1985, a marked decrease in the rate of duodenal ulcer occurred, while the rate of gastric ulcer remained stable. People with low socioeconomic status are more likely to acquire H pylori infection. Individuals who are infected are 3 times more likely to develop gastric ulcer compared to those unexposed to the bacteria.

Since 1989, approximately 500,000 people are estimated to be afflicted with gastric ulcer. The decline in gastric ulcer is in some part attributable to the declining prevalence of H pylori. Although the rate of simple gastric ulcer is in decline, the incidence of complicated gastric ulcer and hospitalization has remained stable, partly due to the concomitant use of aspirin in an aging population.

International

In Denmark, lifetime prevalence of gastric cancer is 1.2% for men and 0.6% for women. The annual incidence of gastric ulcers varies from approximately 1 case per 1000 population in Japan to 1.5 cases per 1000 population in Norway to 2.7 cases per 1000 population in Scotland. For trends in Sweden, see Sadic et al.[2]

Mortality/Morbidity

The mortality rate is approximately 1 case per 100,000 persons, based on the 1979 estimates from the United States. The mortality rate is higher in patients older than 75 years, which can be attributable to a high rate of NSAID use in this age group. The other high-risk groups include people with chronic renal insufficiency and diabetes. Gastric ulcers are also associated with considerable morbidity related to chronic epigastric pain, nausea, vomiting, and anemia.

Sex

In the United States, the prevalence of gastric ulcer has shifted in the past 2 decades, from a disease predominantly affecting males to one that is equally present in both sexes. The male-to-female ratio is 1:1 in the United States and 18:1 in India.

Age

The incidence of gastric ulcer increases with age because of a combination of increasing NSAID use and a high prevalence of H pylori infection in persons older than 50 years. The prevalence of H pylori in elderly individuals is the result of a cohort effect of the generally poorer socioeconomic condition in the United States in past decades compared to today.

History

Patients may present with a wide variety of symptoms, or they may remain completely asymptomatic.

Physical

Physical examination usually is not helpful.

Causes

The 2 major etiological factors for PUD are H pylori infection and NSAID consumption.

Laboratory Studies

Imaging Studies

Other Tests

Procedures

Histologic Findings

The histology of gastric ulcer depends on its chronicity. The surface is covered with slough and inflammatory debris. Beneath this neutrophilic infiltration, active granulation with mononuclear leukocytic infiltration and fibrinoid necrosis may be seen. In chronic superficial gastritis, lymphocytes, monocytes, and plasma cells often infiltrate the mucosa and submucosa.

Medical Care

The medical treatment of gastric ulcers is aimed at restoring the balance between aggressive factors (acid secretion) and mucosal protective factors. In patients infected with H pylori, the most effective treatment is therapy to eradicate the organism and to suppress acid secretion.

In patients with bleeding PUD, volume resuscitation with IV fluid and blood products is the most important initial therapy. An intravenous proton pump inhibitor (PPI) is started. This is followed by checking for acute anemia, thrombocytopenia, or coagulopathy, which needs correction with vitamin K or fresh frozen plasma.

Surgical Care

Consultations

In all patients with acute upper GI hemorrhage, a gastroenterologist should be consulted early. Some institutions have a structured GI bleed team consisting of a gastroenterologist, a surgeon, and an interventional radiologist who are consulted simultaneously for all GI bleeds.

Diet

Insufficient data exist to support any special diet for the healing of gastric ulcers. In the event of acute upper GI bleeding, patients should be kept without food for the initial 24 hours so that endoscopic evaluation can be expedited without fear of aspiration.

Activity

Normal activity is encouraged.

Medication Summary

PPIs given daily or twice daily have an ulcer-healing rate of 80-100% and are the most effective drugs used to treat gastric ulcers. H2 blockers and mucosal protectants (ie, sucralfate, bismuth) are also effective.

Class Summary

These agents act by irreversibly binding the H+/K+ -ATPase pump and effectively suppressing acid secretion.

Omeprazole (Prilosec)

Clinical Context:  Decreases gastric acid secretion by inhibiting the parietal cell H+/K+ -ATPase pump. Indicated for gastric ulcers, duodenal ulcers, GERD, erosive esophagitis, and for eradication of H pylori when combined with other medications.

Lansoprazole (Prevacid)

Clinical Context:  Inhibits gastric acid secretion. Indicated for gastric ulcers, duodenal ulcers, GERD, erosive esophagitis, and for eradication of H pylori when combined with other medications.

Rabeprazole (Aciphex)

Clinical Context:  For short-term (4-8 wk) treatment and relief of symptomatic erosive or ulcerative GERD. If not healed after 8 wk, consider additional 8-wk course.

Pantoprazole (Protonix)

Clinical Context:  Indicated for short-term treatment of GERD associated with erosive esophagitis. Also effective in treating gastric ulcers, including those caused by H pylori.

Esomeprazole magnesium (Nexium)

Clinical Context:  S-isomer of omeprazole. Inhibits gastric acid secretion by inhibiting H+/K+ -ATPase pump at secretory surface of gastric parietal cells.

Class Summary

These drugs inhibit histamine stimulation of H2 receptor in gastric parietal cells.

Nizatidine (Axid)

Clinical Context:  Effectively reduces gastric acid secretion, gastric volume, and hydrogen concentrations.

Ranitidine hydrochloride (Zantac)

Clinical Context:  Effectively reduces gastric acid secretion, gastric volume, and hydrogen concentrations.

Class Summary

Antibiotics and other agents are used as adjuvants to treat duodenal ulcer disease associated with H pylori.

Clarithromycin (Biaxin)

Clinical Context:  Component of drug combination therapy that effectively treats duodenal ulcer or gastric ulcer associated with H pylori infection. Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes, causing RNA-dependent protein synthesis to arrest.

Metronidazole (Flagyl)

Clinical Context:  Component of drug combination therapy that effectively treats duodenal ulcer or gastric ulcer associated with H pylori infection. Active against various anaerobic bacteria and protozoa. Appears to be absorbed into cells. Intermediate-metabolized compounds formed bind DNA and inhibit protein synthesis, causing cell death.

Bismuth subsalicylate (Pepto-Bismol)

Clinical Context:  Component of drug combination therapy that effectively treats duodenal ulcer or gastric ulcer associated with H pylori infection. Antimicrobial and cytoprotective effects produced by bismuth and subsalicylate.

Tetracycline (Sumycin)

Clinical Context:  Component of drug combination therapy that effectively treats duodenal ulcer or gastric ulcer associated with H pylori infection. Treats gram-positive and gram-negative organisms and mycoplasmal, chlamydial, and rickettsial infections.

Amoxicillin (Trimox)

Clinical Context:  Component of drug combination therapy that effectively treats duodenal ulcer or gastric ulcer associated with H pylori infection. Interferes with synthesis of cell wall mucopeptides during active multiplication, resulting in bactericidal activity against susceptible bacteria.

Class Summary

These agents protect GI lining. Shown to be effective in treating peptic ulcers and preventing relapse. Mechanism of action not clear. Multiple doses are required, and agents are not as effective as other options.

Sucralfate (Carafate)

Clinical Context:  Forms viscous adhesive substance that protects GI lining against pepsin, peptic acid, and bile salts. Use for short-term management of ulcers.

Class Summary

These agents are the most commonly used medications to control mild to moderate pain and to decrease inflammation.

Celecoxib (Celebrex)

Clinical Context:  Primarily inhibits COX-2. COX-2 is considered an inducible isoenzyme, induced by pain and inflammatory stimuli. Inhibition of COX-1 may contribute to NSAID GI toxicity. At therapeutic concentrations, COX-1 isoenzyme is not inhibited, thus incidence of GI toxicity, such as endoscopic peptic ulcers, bleeding ulcers, perforations, and obstructions, may be decreased when compared to nonselective NSAIDs. Seek lowest dose for each patient.

Neutralizes circulating myelin antibodies through anti-idiotypic antibodies; down-regulates pro-inflammatory cytokines, including INF-gamma; blocks Fc receptors on macrophages; suppresses inducer T and B cells and augments suppressor T cells; blocks complement cascade; promotes remyelination; may increase CSF IgG (10%).

Has a sulfonamide chain and is primarily dependent upon cytochrome P450 enzymes (a hepatic enzyme) for metabolism.

Further Inpatient Care

Further Outpatient Care

Inpatient & Outpatient Medications

Deterrence/Prevention

Complications

Prognosis

References

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Gastric ulcer with punched-out ulcer base with whitish fibrinoid exudates.

Gastric ulcer (lesser curvature) with punched-out ulcer base with whitish exudate.

Gastric cancer. Note the irregular heaped up overhanging margins.

Gastric cancer with ulcerated mass.