Peptic Ulcer Disease (PUD)

 

Epidemiology and Etiology:

    • Middle aged to older
    • M > F
    • Risk factors:
      • H. pylori infection (present in virtually all cases of duodenal and 70% of gastric ulcers) (only 10-20% infected develop ulcers)
        • Inducing inflammation and cytokines
        • Damage of surface epithelial cells
        • Enhances acid secretion
        • Impairs bicarbonate production
        • Thrombotic occlusion of surface capillaries promoted by a bacterial platelet-activating factor
        • leakage
      • impaired blood flow / Ischemia / shock
        • Cigarettes
        • Severe systemic stress
      • Drugs:
        • NSAIDs
        • ASA
        • Corticosteroids (high dose, repeated)
      • Toxins:
        • alcohol
      • delayed gastric emptying
      • gastric hyperacidity
        • Zollinger-Ellsion syndrome
      • Alcoholic cirrhosis
      • COPD
      • Hypercalcemia (stimulates acid production):
        • Chronic renal failure
        • Hyperparathyroidism
      • Psychologic stress and personality
    • Pathogenesis:
      • Imbalance between defense mechanisms and damaging forces
      • Mucosal defense:
        • Mucous secretion
        • Bicarbonate secretion
        • Mucosal blood flow
        • Apical surface membrane transport
        • Epithelial regenerative capacity
        • Prostaglandin elaboration
      • Damaging forces:
        • Acid
        • pepsin

 

Common sites:

    • duodenum
      • anterior wall
      • a few centimeters from the pylorus
    • stomach (antrum usually)
      • lesser curvature
    • GE junction (reflux)
    • Gastrojejunostomy margins
    • Within or adjacent to Meckel diverticulum

 

Gross features:

    • solitary usually
    • <4cm
    • round to oval
    • sharply punched out defect
    • relatively straight walls
    • margin flush with surrounding mucosa or slightly elevated (heaping up is rare)
    • base is smooth and clean
    • may see spokelike mucosal folds radiating from the ulcer (from fibrosis)
    • edematous and erythematous mucosa surrounding

 

Histologic features:

    • ulcer – breach in the mucosa extending into the submucosa or deeper
    • layers of an ulcer (superficial to deep):
      • necrotic debris
      • acute inflammation
      • granulation tissue
      • fibrosis
        • vessels within may be thrombosed
    • concurrent chronic gastritis almost always

 

Immunophenotype:

Marker:

Sensitivity:

Specificity:

 

 

 

 

Molecular features:

    •  

 

Other features:

    • treatment of H. pylori  helps heal and prevent further ulcers
    • clinical:
      • epigastric pain (may be chest or back pain in some cases)
        • gnawing, burning, aching
        • worse at night
        • 1-3h after meals during the day
        • relieved by alkalis
        • relieved by food
      • nausea / vomiting
      • bloating
      • belching
      • weight loss
      • anemia
    • complications:
      • bleeding
      • perforation
      • obstruction (edema/scarring)

 

References:

    • Robbins 2005