Module 2 Minicourse 2 Ulcer Disease

INTRODUCTION

Peptic ulcer, often called "ulcers," is a common gastrointestinal complaint. The intestinal tube is a "sounding board" structure for the nervous system. During acute psychic stress (worry, concern, competition), we are all aware of such symptoms as loss of appetite, tendency to loose stools, and even nausea and vomiting.

Disordered autonomic nervous system function also occurs in longer lasting anxiety with such physiologic changes as increased production of gastric acid, rapid emptying of the stomach, diarrhea or constipation, increased or decreased appetite.

Abdominal pain from the gastrointestinal tube is typically vague, often rhythmic and difficult to localize. The symptoms related to peptic ulcer are probably the most characteristic of all abdominal discomfort but even they can be variable.

Characteristic symptoms of gastrointestinal involvement are nausea, vomiting, diarrhea, constipation, abdominal discomfort, dysphasia, and jaundice. One can usually localize symptoms as to which end of the gut is involved, but innervation is so interrelated at times even this is difficult.

2.2 Ulcer Disease

On completion of this minicourse you will be able to:

1. List the signs, symptoms, causes and natural history of ulcer of the:

a. esophagus

b. stomach

c. duodenum

2. Distinguish normal and abnormal structure and function of the G.I. System associated with each of the ulcer diseases described in Objective 1.

3. Describe the laboratory and x-ray procedures and data which are useful for the diagnosis of the ulcer diseases described in Objective 1.

4. Construct a treatment plan for each of the ulcer diseases described in Objective 1 which includes both pharmacologic and nonpharmacologic (particularly psychologic) approaches.

5. Construct a differential diagnosis and a treatment plan for each ulcer disease described in Objective 1, given signs, symptoms, and laboratory and x-ray data.


Section 1: Signs, Symptoms, Causes and Natural History

Ulcers are a defect of part of the gastric or intestinal wall. They are usually localized and may be superficial, deep or perforated (i.e. having eroded through the mucosal lining). They may occur anywhere along the G.I. tract. They are most common in the duodenum, stomach, esophagus and jejunum, in that order. The ulcer itself usually appears as a deep punched out area overlapping edges, usually less than 4 cm. in diameter. The base of the ulcer is generally grayishwhite and may be covered by necrotic or bloodtinged material. After a period of time, fibrosis develops, which may become severe. The most important symptom of ulcer is abdominal distress. This is most often present in the upper abdomen and epigastric region, or it may be substernal. Characteristically, it is a "hunger pain," which may progress to a gnawing or burning epigastric discomfort occurring onehalf to three hours after eating. In the presence of active ulcer, the patient is very often awakened in the night by this discomfort. Typical of the pain is the fact that it is relieved by alkaline materials such as baking soda, milk, or almost any food which helps to neutralize the increased hydrochloric acid that is present in the stomach. The pain, if untreated, tends to wax and wane and finally disappear spontaneously. Usually the discomfort of ulcer is greater when the stomach is empty, and is relieved by anything that dilutes hydrochloric acid. Tasty spicy foods, however, tend to produce more certain return of ulcer distress. The cause of ulcer discomfort is not certain, although it seems more likely to be associated with the increased hydrochloric acid present in the stomach of most people with peptic ulcer, and perhaps with the hypermotility which can be recognized in the gastric end of the esophagus and in the entire stomach. Bouts of ulcer symptoms last from a few days to a few weeks and then spontaneously clear, to recur, especially during times of stress in the patient's life. Presumably, the free periods represent healing of the ulceration. Recurrent ulcer is most common during the patient's productive years but may occur in children and senior citizens, where it is often overlooked. It has been observed that ulcer disease "flares up" in the spring and fall in temperate climates.

The most common site for ulceration of the upper gastrointestinal tract is the duodenum. Ninetyfive percent of all "peptic" ulcers occur here. However, gastric (stomach) ulcer has symptoms often indistinguishable from duodenal ulcer. Esophageal ulceration usually appears at the junction of the esophagus and stomach, especially if the sphincter here is incompetent. The symptoms of esophageal ulcer and esophagitis are more likely to be substernal with the burning distress reflected to shoulders and neck. This is often called "heartburn."

An upper G.I. bleed presentation can vary from exsanguinating hematemesis to asymptomatic melena. Possible sites of an upper G.I. bleed include:

  
  (1) bleeding from upper or     (7) gastric neoplasm
      lower respiratory tract    (8) gastric ulcer
  (2) esophagitis                (9) gastritis
  (3) esophageal neoplasm       (10) anastomotic (marginal) ulcer
  (4) esophageal varices        (11) duodenal ulcer
  (5) esophageal ulcers         (12) duodenitis
  (6) hiatus hernia

Incidentally, names such as "heartburn" or "gas" may just be the patient's interpretation of his discomfort and still need to be explored with him before the clinician actually understands the nature of the distress.

Complications of Peptic Ulcer

With the complications that occur in ulcer of the esophagus, stomach or duodenum, symptoms other than the above appear. In bleeding peptic ulcer there may be vomiting of fresh or digested blood; the latter being brownish and/or "coffee ground" in color. Bleeding is often associated with stools which are as black and shiny as tar and frequently loose. There are general symptoms of weakness, lightheadedness, and sometimes fainting accompanying a bleeding ulcer.

Perforation of gastrointestinal ulcer of stomach, esophagus or duodenum is rare, but does occur and will be discussed under the Acute Abdomen. Obstruction of the outlet of the stomach may gradually occur when the patient has had recurrent duodenal ulcer year after year.

Probably the chief complication of inflammation and ulcer in the lower esophagus is stricture formation. A stricture is a fibrotic scarring of the esophagus with the loss of ability of that portion to dilate and allow food to enter. Strictures usually result in difficulty in swallowing (dysphasia).

Physical Findings

The physical findings in ordinary peptic ulcer are scanty. There may be epigastric or right upper quadrant tenderness with deep palpation. The rectal examination is exceedingly important in all examinations of the gastrointestinal tract, and in this case one may discover black, tarry stool on his finger as well as evidence of occult bleeding from the G.I. tract.

Even in bleeding peptic ulcer it is unusual to find more than just moderate upper abdominal discomfort to examination. If there is obstruction of the duodenum secondary to repeated duodenal ulceration, the stomach may remain full for hours after a meal so that a "succusion splash" (a splashing sound heard when the patient is shaken, indicating the presence of air and fluids in the body cavity) may be detected if the patient's upper abdomen is jostled. The abdomen may appear to be distended and the gas bubble in the stomach larger than usual. One may hear repeated peristaltic activitv on auscultation of the epigastrum and left and right upper quadrants. The physical findings of perforated peptic ulcer will be discussed under Acute Abdomen.

EXERCISE 1

OBJECTIVE 1 Questions

1. What are the classical characteristics of the peptic ulcer?

2. How does one distinguish gastric and duodenal ulcers?

3. Why are ulcers in the esophagus, stomach or duodenum called "peptic" ulcers?

4. What complications occur with peptic ulcer?

5. What symptoms may distinguish peptic ulceration of the esophagus from that occurring in the stomach or duodenum?

EXERCISE 1 DISCUSSION

OBJECTIVE 1 Answers

1. Epigastric or substernal distress k to 3 hours after meals; relieved by food or alkaline substances.

2. One cannot often do so by history nor by physical examination.

3. Because they are all related to the gastric phase of digestion. This in turn focuses concern on production of gastric juices which contain hydrochloric acid and pepsin.

4. Bleeding, perforation or obstruction of the upper gut where the ulcer has formed.

5. Esophageal ulcer is characterized by substernal burning and discomfort, radiating to neck and shoulders, increased with recumbency and relieved by sitting up and taking antacids.

Section 2:
OBJ. 2. Distinguish normal and abnormal structure and function of the G.l. system associated with each of the ulcer diseases described in Objective 1.

Ulcer Disease Pathophysiology

Although peptic ulcer has been extensively studied, the cause remains unknown. Factors which seem to be at work include increased gastric secretions, both hydrochloric acid and pepsin. Conditions for ulcer formation appear to require some added lowering of resistance of the gastric, esophageal or duodenal mucosa before ulceration occurs.

Under chronic stress there is an increase in gastric secretions and a decrease in protective glycoproteins produced by the digestive mucosa. Peptic ulcer seems to be most often found in compulsive, hardworking individuals.

Acidity is generally lower in gastric than in duodenal ulcer, which has led to the speculation that in those with gastric ulcer there is even less resistance to peptic ulceration.

Acute ulceration of the stomach also occurs during heavy use of alcohol, or with infection or severe injury. The resultant ulcer is usually "superficial" and heals within a few days.

Peptic ulcer of the duodenal type, however, is recurrent and often chronic, burrowing deep and healing slowly with resultant scarring. If in the duodenal area, repeated ulceration and healing can ultimately cause narrowing and obstruction. The following schematic pictures may aid in understanding pathologic changes which occur.

As mentioned previously, inflammation and ulcer of the esophagus may result in symptoms of dysphagia if a stricture forms. It should be remembered, however, that difficulty in swallowing may also result from other causes such as esophageal cancer and esophageal motility disorders (a group of disorders in which esophageal peristaltic function is deranged without anv anatomical defects).

Dysphagia and Esophageal Problems

Difficulty in swallowing may be due to actual physical obstruction of the esophagus, such as occurs when a large foreign body is swallowed ant lodges in the esophagus, or when a new growth appears in the esophagus and gradually makes swallowing more ant more difficult; e.g. esophageal cancer.

EXERCISE 2

OBJECTIVE 2 Questions

1. What personality factors may be related to cause of peptic ulcer?

2. What physiologic changes can one identify as related to peptic ulcer?

3. How long do peptic ulcers last?

4. How many ulcers does one usually have at a time?

5. How is dysphagia related to peptic ulcer? What other causes of this symptom do you know?

EXERCISE 2 DISCUSSION

OBJECTIVE 2 Answers

1. A tendency toward compulsiveness to achieve success, ambition and other stressproducing states.

2. Increased gastric secretions, both acid (HC1) and pepsin, reduced production of protective mucoproteins in the stomach.

3. Those due to acute local or systemic stress are superficial and heal quickly. Those related to chronic ulcer producers are likely to remain present for several days or weeks, be recurrent and produce scarring with healing.

4. In chronic ulceration, there is usually one ulcer at a time, but new ulcers occur from time to time during the productive and stressful years of life.

5. Dysphagia (difficult swallowing) is from many causes, but increased gastric acid with reflux of HC1 into the esophagus may over a long period of time produce inflammation and ulceration of the lower esophagus with swallowing difficulties both during ulceration and healing. Neoplasm may also cause dysphagia, as well as esophageal motor disorders.


SECTION 3: Lab and X-ray findings in peptic Ulcer

OBJ. 3. Describe laboratory and xray procedures and data which are useful for the diagnosis of the ulcer diseases described in Objective 1.

Laboratory and Xray Findings in Peptic Ulcer

The ordinary clinical laboratory tests have little to offer in the study of peptic ulcer. Even when the complications of obstruction, bleeding or perforation are present, only a few laboratory tests are useful.

Gastric aspirate may be clear despite active duodenal bleeding. Therefore, do not rule out duodenal ulcer unless bile is also present in aspirate.

It is important to recall that occasionally a large gastric ulcer develops in the presence of gastric carcinoma. Gastric carcinoma occurs ten times more often in the stomach which is devoid of hydrochloric acid. The condition of achlorhydria (no gastric acid), oddly enough, is at times associated with ulcerlike symptoms including epigastric fullness, postprandial distress and even nausea and vomiting. Characteristic of the vomitus is that it does not have a sour taste because of the absence of hydrochloric acid. In ulcer of the stomach this could be an important clinical clue to gastric carcinoma. It should be stressed, however, that gastric carcinoma is a rare disease, and the most common peptic ulcers are duodenal.

Blood chemistry determinations will be normal in peptic ulcer unless there has been longstanding symptoms of ulcer associated with overuse of alkaline materials; or in the presence of obstruction of the outlet of the stomach. If much hydrochloric acid is lost through vomiting, blood electrolytes may show a relative alkalosis resulting from marked reduction in serum chlorides, and only mild decrease in sodium and potassium.

If bleeding peptic ulcer is present in whatever site, anemia may be reflected in the blood count, which will show a reduction in total red cell count, hemoglobin content and hematocrit. As a rule the final picture will be that of iron deficiency anemia. Bleeding can be detected by testing the feces for presence of blood (guaiac test).

Xrays of the upper gastrointestinal tract are the most important source of confirmation of the clinical hypothesis of peptic ulcer. Ulceration of the esophagus is difficult to demonstrate, but may be inferred if the xray during fluoroscopy reveals spasm of the lower portion of the esophagus in conjunction with ulcer symptoms. Gastric ulcer may be recognized by discovery of the ulcer crater during fluoroscopy and also by sharp, spastic contractions narrowing the stomach in the neighborhood of the ulcer. Duodenal ulcer most often is recognized during fluoroscopy if the examiner is able to put his hand on the patient's abdomen and flatten out the barium stream in the ulcer crater. Longstanding or repeated ulceration of the duodenum gives rise to much distortion of the duodenal bulb which the radiologist may interpret as duodenal ulcer even though no specific crater can be demonstrated.

Special evaluation of upper gastrointestinal lesions, including peptic ulcer, may be carried out by use of the flexible gastroscope. The most fruitful source of information about swallowing difficulties are direct and xray evaluation of the esophagus. Changes in structure or function of the esophagus may be obtained by xray of the esophagus under fluoroscopy. This is done by ingestion of the contrast medium, barium. Fluoroscopic examination may show a dilated esophagus above a narrow inlet into the stomach. When the patient is put in the supine position and his feet elevated, demonstration of diaphragmatic esophageal hernia may be possible. Rarely, xray may reveal an esophageal diverticulum. Direct vision through the esophagoscope is the final step in evaluation of lesions in this part of the gastrointestinal tract.

EXERCISE 3

OBJECTIVE 3 Questions

l. How may an ulcer of the duodenum be visualized before surgery?

2. Can any laboratory tests prove the presence of ulcers?

3. What laboratory techniques can one utilize in the diagnosis of peptic ulcer?

4. When will gastric analysis be of value in the study of peptic ulcer?

5. What changes will the bleeding peptic ulcer produce in the CBC and hematocrit?

EXERCISE 3 DISCUSSION

OBJECTIVE 3 Answers

1. Either by fluoroscopic (xray in action) examination or by gastroesophagoscopy.

2. No, not in all finality.

3. a. determination of gastric analysis b. determination of CBC (complete blood count) c. stool exam for blood (guiac test)

4. Gastric analysis will usually reveal high to normal gastric acid. Absence of hydrochloric acid (achlorhydria) occurs rarely but when an ulcer appears under these circumstances the possibility of ulcer with a carcinoma should be considered.

5. A bleeding peptic ulcer will result in a reduction in red cell count, hemoglobin concentration and hematocrit percentage.


Section 4: Treatment of Peptic Ulcer


OBJ. 4. Construct a treatment plan for each of the ulcer diseases described in Objective 1 which includes both pharmacologic and nonpharmacologic (particularly psychologic) approaches.

Treatment of Peptic Ulcers

Even though the cause of peptic ulcer is really unknown, the fact that it is usually associated with elevated gastric acids has given rise to what is successful treatment from the standpoint of relief of symptoms and perhaps, as a result, more rapid healing of the ulcer. The rationale of treatment of an ulcer with alkaline materials comes from understanding that residual high levels of hydrochloric acid remain after the rapidly emptying stomach has processed the last meal and passed it on into the duodenum. Antacids are given at 1 and 3 hours following meals, and at bedtime. The patient must clearly understand the use of antacids in this respect. The "coating of the stomach" with antacids is an unproven mechanism in the use of alkaline materials. If antacids are used, a high potency antacid, such as Mylanta II, is preferred.

In reality, antacids are rarely used anymore as firstline treatment of peptic ulcers. This is due to the development of more potent and more convenient antiulcer agents. These agents include a group of drugs known as the H2 blockers which suppress gastric acid secretion by virtue of their blockade of histamine type receptors on acidproducing cells of the stomach. The H blockers currently available include cimetidine, vanitidine, famotidine and n?izatidine. Another antiulcer agent available is sucralfate. This drug acts by a different mechanism than the H2 blockers probably by some type of as yet unclarified local protective effect. As noted these newer agents are much more convenient to use than antacids and may be effective with doses ranging from once a day to four times per day depending on the agent.

Although the use of baking soda (sodium bicarbonate) has been warned against, it gives prompt relief in the case of peptic ulcer where there is increased hydrochloric acid. The patient always emits a large belch after use of this quickly neutralizing substance, and ascribes his discomfort to "gas." The gas, however, has actually been released from the bicarbonate as it combined with the hydrochloric acid producing water, sodium chloride and the gas carbon dioxide (which is the belch).

Diet therapy in peptic ulcer has undergone many changes over the last 30 years. There are diets so strict that food must be taken every hour or two, alternating with antacids, and the food must be of the softest, most highly proteinaceous type to produce the greatest neutralization and the least nonproducing of hydrochloric acid. This, however, is not used very often in modern therapy. Ambulatory care of the active ulcer patient probably only requires that the patient use a normal daily diet. Caffeine, tobacco smoking and alcohol use are discouraged as these increase gastric acid production.

The use of antispasmodics in the treatment of peptic ulcer should be done with caution and understanding! They do slow gastric emptying time and as such may allow more complete mixing of food and neutralization of acid. Less gastric juice is produced. In partial obstruction of the duodenum, however, antispasmodics may lead to complete obstruction.

Sedation is occasionally used in the patient with peptic ulcer with good effect. Peptic ulcer, a common disease of civilization, comes in people with perfectionistic responses to the stress of everyday life. Both stomach acid and activity are increased. Therefore, the use of a mild sedative for a short period of time has every justification in treatment of peptic ulcer.

Surgery as treatment of peptic ulcer is used only in the case of complications such as perforation, constriction or uncontrollable bleeding and is undertaken only after the most careful study of the patient. Gastric resection or gastroenterostomy are not panacea for duodenal ulcer and consideration for their use is in the realm of the internist and surgeon.

Esophageal inflammatory disease is first approached by the use of an antacid with cimetidine or another H2 blocker in order to reduce gastric acid. The patient must be encouraged to stop smoking for the reasons previously mentioned. In addition, obese patients are instructed to lose weight and all patients are advised to elevate the head of their beds (approximately 6 inches) since this is thought to reduce nocturnal esophageal acid exposure. If there is a significant esophageal stricture, dilatation will often bring relief.

Stress management techniques are also occasionally helpful in the treatment of ulcers. They have fewer side effects, are less costly than sedatives, and give the patient the feeling of control over his life.

EXERCISE 4

OBJECTIVE 4 Questions

1. What dietary alterations are advisable in the treatment of peptic ulcers?

2. Explain the purpose in use of antispasmodics in treatment of ulcer.

3. Is "gas" a symptom of peptic ulcer?

4. Indicate the rationale of antacid use in ulcer therapy.

5. When is sedation used in treatment during an ulcer regimen?

6. What are the indications for surgery in ulcer?

7. Outline the medical and surgical treatment of ulcer or inflammation of the lower esophagus.

EXERCISE 4 DISCUSSION

OBJECTIVE 4 Answers

1. Two changes may be made:

a. normal diet with 3 to 4 meals daily b. reduction of those foods which increase or leave large amounts of gastric acidcoffee, alcohol, tobacco

2. Antispasmodics (anticholinergics) are used to:

a. reduce gastric motility

b. decrease production of gastric juice

3. No. "Gas" means many things to many patients: belching, flatulence, epigastric fullness, rumbling noises.

4. Antacids are used in ulcer to neutralize extra gastric acid remaining following stomach emptying.

5. When anxiety is a prominent feature of the patient's illness.

6. Surgery is necessary in ulcer therapy if the complications of penetration

(perforation), obstruction or uncontrollable bleeding have occurred.

7. Usually at least three steps are utilized in treatment of lower esophageal inflammatory disease:

a. antacid and cimetidine to reduce gastric acid

b. dilatation of esophageal stricture

c. stop smoking


Section 5: Differential Diagnosis


Objective 5. Constuct a differential diagnosis and a treatment plan for each ulcer disease described in objective 1, given signs, symptoms, and laboratory and x-ray data.

             Differential diagnosis of acid-peptic diseases
                History              Physical Exam         Lab               x-ray       Endoscopy
Gastric ulcer   Post-parandial epi-  Tender epigastrium   Anemia present   Ulcer crater  Ulcer Crater
                gastric discomfort                        or increased     
                food relief                               acid

Duodenal ulcer  Same, back pain at   Same, plus tender    High gastric     same, scarring Ulcer crater
                times                right upper quad-    acid, anemia     narrowing
                                     rant

Angina          Substernal pain      Pallor, sweating     Normal acids     Normal upper   Normal
pectoris        with extertion;      tachycardia          no anemia        G.I. x-ray
                relief with
                nigroglycerin

Esophagitis     Substernal and       Few findings         Normal acid,     Esophogeal      Inflamed esopha-
                epigastric pain-                          possible anemia  mucosal irreg-  gous, sometimes
                food relief, supine                                        ularity, crater an ulcer
                                                                           rare, hiatal
                                                                           hernia often
                                                                           seen


EXERCISE 5

OBJECTIVE 5 Questions

1. A 45 year old insurance salesman complains of substernal discomfort of a burning, squeezing nature which radiates to his jaw and shoulders. What is your order of questions? (Select the first two you'll ask.)

a. 2, 1

b. 1,5

c. 5

d. 4, 3

e. 2, 5

2. If the same patient has a story of sour eructations, alkali and food relief, and increased distress when supine, what tests would you order?

1. upper G.I. series (Xrayfluoro)

2. barium enema

3. electrocardiogram

4. CBC

5. exercise test

a. 1, 2

b. 1, 4

c. 3, 5

d. 5

e. 3

If endoscopy reveals a red, thickened lower esophagus with a shallow ulceration, what treatment will you order?

1. dilatation

2. operative repair

3. antacids

4. cimetidine

5. antispasmodic

a. 3, 4

b. 2, 3

c. 5

d. 4, 5

e. 1

4. Select laboratory studies to help verify a suspected duodenal ulcer (best choices):

1. endoscopy

2. colon xray

3. electrolyte studies

4. CBC

5. xray (barium)

a. 1, q

b. 2, 3, 4

c. 4, 3

d. 1, 4

e. 1, 4, 5

EXERCISE 5 DISCUSSION

OBJECTIVE 5 Answers

1. d. Time of pain occurrence helps distinguish between esophageal pain and coronary artery insufficiency pain (angina). Relief with arising helps esophageal distress; cessation of work will relieve anginal pain.

2. b. Supine distress suggests increased acid reflux with esophageal component. Fluoroscopy of esophagus and stomach (upper G.I. series) and CBC (looking for anemia or leukocytosis) gives clue to ulceration.

3. a. Treatment for esophageal inflammation from gastric reflux requires neutralization of acid and reduction in its production.

4. e. Anemia is a clue to ulcer when it is suspected although upper G.I. series or endoscopy are best bets for diagnosis.