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What is ulcer?The ulcer is a disease characterized by the presence of a deep lesion in the mucosa of the stomach ( gastric ulcer ) or duodenum ( duodenal ulcer ). Occurs as a result of an imbalance between aggressive factors and defensive factors of the gastroduodenal mucosa, so that it loses its integrity.
At ulcer development play a very important role acid secretion and gastric juice, since in the absence ulcer acid not exist. In addition, there is a good correlation between the antisecretory and ulcer healing. However, the disease occurs only when there is an alteration of the defense mechanisms of the mucosa, caused by aggressive external factors. Of these factors, the most important are the nonsteroidal antiinflammatory drugs (NSAIDs) and a bacterium called Helicobacter pylori , so the presence of the bacteria was confirmed in 95% of duodenal ulcers and 70% of ulcers gastric.
bacteria is extremely common in developing countries, where 80% of the population has it. In developed countries is also very common, appearing in 20-50% of the population. Addition of peptic ulcer, it may also cause gastritis (usually precedes the ulcer), dyspepsia or lymphoma but most infected by this bacterium are asymptomatic and, therefore, do not need treatment.
Apart from Helicobacter pylori and intake of NSAIDs, there are other factors that are associated with the disease and the consumption of snuff, increased gastric secretion compared to food in the case of duodenal ulcer, family history (which are present in 20-50 % of cases) or blood group O (which has a 30% increased risk). In some cases the reason for appearance of the ulcer is not known; this happens in 10% of gastric ulcers.
ulcer is a very common condition that affects 10% of the population and is more prevalent on persons aged between 55 and 65 years and rarely appeared before 40 years. Although years were more frequent gastric ulcers are more common now duodenal.
Symptoms of an ulcerThe most common symptom of peptic ulcer is abdominal pain; it is a feeling that the patient described as burning, stabbing pain, or painful feeling hungry. Typically appears between 1.5 and 3 hours after meals and is relieved by food intake or taking antacids. It is also very characteristic for the presence of pain during the night waking the patient, between midnight and 3am.
Often there may be other associated symptoms such as bloating, fat intolerance, belching, weight loss, nausea and vomiting (the latter especially in gastric ulcers.)
Some patients have no symptoms and the disease manifests itself first as one of its complications (perforation, bleeding ...).
The natural history of ulcer is that of spontaneous healing and subsequent recurrence, so that 80-90% of patients will have a recurrence within two years. With the drugs available at present, the tendency is to endure a single outbreak without subsequent recurrence.
Complications of ulcerThe appearance of an ulcer may involve any of the following problems or complications:
Gastrointestinal bleedingIt is the most common complication of the ulcer, appearing in 20% of patients with the disease, usually in patients over 50 years. Furthermore, this complication is the most common cause of upper gastrointestinal bleeding in the population. Bleeding is usually painless and is diagnosed by endoscopy, which also serves for sclerosing (hardening an organ or tissue) and stop the bleeding ulcer bleeding so.
DrillingAcute ulcer perforation in the peritoneal cavity occurs in 6-10% of the cases. Drilled more often duodenal ulcers gastric, and clinical usually involves an intense shooting pain that extends to the entire abdomen due to the release of intestinal acid contents into the peritoneal cavity, causing irritation (chemical peritonitis ). The abdominal wall contracts and hardens producing called "abdomen on wood." When an X-ray will be seen outdoors in the peritoneal cavity (pneumoperitoneum). The treatment is surgical.
PenetrationUlcer penetration is to a neighboring perforation body, so that it penetrates. Most often, a duodenal ulcer penetrating the pancreas, but also can penetrate other organs. It usually manifests as a change in the usual ulcer symptoms and poor response to treatment. The treatment of this complication is surgical.
Obstruction (pyloric stenosis)This is the obstruction of the gastric outlet orifice into the remaining intestine (pylorus) due to ulcer. Appears in 2% of ulcers and is manifested by vomiting, early satiety, weight loss, increased abdominal pain after eating, etc.. The definitive diagnosis was given endoscopy, and treatment is surgical.
Diagnosis of an ulcerAlthough the characteristics of the pain can be very typical ulcer, further tests must for viewing and diagnosis, as are many diseases associated with abdominal pain.
Physical ExaminationPhysical examination is usually normal in patients with uncomplicated ulcer; they can feel pain with deep palpation of the abdomen, but this is a really very little specific. However, there are signs that research can reveal the existence of any complications such as pallor in the case of hemorrhage, or hard abdomen in the case of a perforation. Also, look for signs of associated diseases (cardiac, respiratory or liver), which increase the risk of complications.
X-ray contrastIn this technique the barium display images from ulcer suggestive used, identifying 70% of cases.
EndoscopyIt is the most reliable method for the diagnosis but not the test that is performed routinely, reserving only for borderline cases, for cases in which the X-ray ulcer is observed but there is strong suspicion, or for patients with bleeding digestive. In the case of gastric ulcers is forced to perform an endoscopy and sample the edges of the ulcer, since you have to exclude the possible existence of malignant lesions, which are more common in gastric ulcers in the duodenum.
Detection of Helicobacter pyloriBecause the relationship between this bacterium and ulcer, determine if there is infection of the bacteria, for which the breath test, or through a sample of gastric mucosa was performed if endoscopy is used.
Analysis of gastric acid secretionSometimes you have to study for the basal gastric secretion in response to food, as well as findings of gastrin (a hormone that stimulates the secretion of hydrochloric acid). Thus, some situations where clinical states due to increased acid or gastrin-producing tumors (Zollinger-Ellison syndrome), which produce a lack of response to standard treatment is discarded secretion.
Treatment of ulcerAn ulcer can be treated medically or surgically. Consider two:
Medical treatmentCurrently there are many drugs that can be used for ulcer disease. Some of the most important are:
- Antacids are administered one hour after meals, and are useful for pain relief. Aluminum hydroxide and magnesium hydroxide are used.
- H2 receptor antagonists: these include cimetidine, ranitidine or famotidine, and their action is based on the inhibition of acid secretion.
- Mucosal protective agents: sucralfate used one hour before meals and at bedtime. Also belongs to this group colloidal bismuth.
- Synthetic prostaglandins: enprostil and misoprostol; particularly marked in preventing ulcers associated with taking NSAIDs.
- Inhibitors Proton pump are the most potent acid antisecretory, and more employees. These organizations include omeprazole, lansoprazole, pantoprazole and rabeprazole, and should be administered 30 minutes before meals.
Treatment guidelinesIn addition to symptomatic relief they get the drugs indicated for the treatment of ulcer currently recommended eradicate Helicobacter pylori, ie, those patients who are infected with the bacteria need to take antibiotics (amoxicillin and clarithromycin) with omeprazole for 1-2 weeks.
Subsequent to this eradication therapy, the patient should take an inhibitor of the proton pump or an H2-receptor antagonist for 8 weeks if the ulcer is gastric. In case of a duodenal ulcer do not need to take any drugs after eradication, unless you have symptoms or have had gastrointestinal bleeding, in which case it will take the same as for gastric ulcer but for 4-6 weeks.
Surgical TreatmentDue to the high efficacy of medical treatment of ulcer, surgery is reserved for a few situations: the presentation of a complication such as bleeding or perforation, in those cases where it can not rule out a malignant component and due to the presence of a refractory, ie, that ulcer that has not healed after more than 12 weeks of proper medical treatment. ulcer
are many techniques used for surgical treatment, classically gastric ulcer was treated with resection of the stomach and duodenal ulcer by vagotomy (technical in which nerves are severed involved in acid secretion, so that this decreases).