Pathophysiology:Acid is secreted by the parietal cells of the gastric mucosa. The mucosa is protected by the mucus gel layer. The normal stomach maintains a balance between protective factors (mucus and bicarbonate secretion) and aggressive factors (acid secretion and pepsin). PUD mainly results from an imbalance of the aggressive gastric factors and defensive mucosal barrier factors. Some environmental and host factors also contribute to ulcer formation by increasing gastric acid secretion or weakening the mucosal barrier.
Causes of Peptic Ulcer disease (PUD):1. Helicobacter pylori causes 70–80% of Peptic Ulcer diseases. The incidence of H. pylori infection is high in developing countries. Its incidence is decreasing in United States due to higher standards of living associated with higher levels of education and better sanitation. H. pylori infection increase acid secretion and also predisposes to ulcer disease by disrupting mucosal integrity. H. pylori is a short, spiral-shaped, microaerophilic gram-negative bacillus that have the ability to colonize and infect the stomach. H. pylori gastritis is the most common cause of MALT lymphoma. Patients with H pylori infection have 12-16-fold increased risk of developing gastric cancer. Most common route of H. pylori infection is either oral-to-oral (stomach contents are transmitted from mouth to mouth) or fecal-to-oral (from stool to mouth) contact. Parents and siblings seem to play a primary role in transmission.
2. NSAID (Nonsteroidal anti-inflammatory drugs like Brufen) accounts for approximately 20-30% of Peptic Ulcer disease. PUD is believed to develop secondary to the decrease in prostaglandin production resulting from the inhibition of cyclooxygenase. The topical effects of NSAIDs are superficial gastric erosions and petechial lesions. The greatest risk of developing an ulcer occurs during the first 3 months of NSAID use.
3. Environmental factors including smoking, excessive alcohol intake and extreme emotional or physical stress (e.g. trauma, burns), Gastrinoma (Zollinger-Ellison syndrome), Bile reflux, Pancreatic enzyme reflux, Radiation, Crohn's disease, Bacterial or viral infection are some other causes of PUD.
4. Genetics: More than 20% of patents have a family history of Peptic Ulcer disease.
Various conditions of Acid Peptic Disease:1. Gastric Ulcer: Here ulcer formation can be limited to a part of the stomach (like antral) or there may be involvement of whole of the stomach (Pangastric).
2. Duodenal Ulcers: More than 95% of duodenal ulcers are found in the first part of the duodenum; most are less than 1 cm in diameter.
3. Stress-Induced Gastritis: Also referred to as stress-related erosive syndrome, stress ulcer syndrome, and stress-related mucosal disease. In stress gastritis, gastric acid secretion is invariably either normal or decreased. So acid hypersecretion is not a significant etiological factor, instead the breakdown of the mucosal defense mechanism is the primary cause. It causes mucosal erosions and superficial hemorrhages in critically ill patients or in patients with extreme physiological stress, resulting in minimal-to-severe gastrointestinal blood loss. Examples are patients with massive burn injury, head injury, sepsis, severe trauma, and multiple system organ failure.
4. Autoimmune gastritis: There is a chronic inflammation of the stomach mucosa leading to loss of gastric glandular cells and their eventual replacement by intestinal and fibrous tissues. As a result, the stomach's secretion of hydrochloric acid, pepsin and intrinsic factor is impaired leading to digestive problem. It is primarily related to the deficiency in cobalamin. The disease has an insidious onset and progresses slowly.
5. Infectious Granulomatous gastritis: Though rare, tuberculosis may affect the stomach and cause caseating granulomas. Similarly, Fungi can also cause caseating granulomas and necrosis especially in immunosuppressed patients.
6. Noninfectious granulomatous gastritis: Noninfectious diseases causing gastric granulomas include Croh'n disease, sarcoidosis, and isolated granulomatous gastritis.
7. Ischemic gastritis: It is believed to result from atherosclerotic thrombi arising from the celiac and superior mesenteric arteries.
8. Lymphocytic gastritis: This is a type of chronic gastritis seen in middle-aged or elderly patients.
9. Eosinophilic gastritis: It can be associated with eosinophilic gastroenteritis, usually seen in parasitic infestations. Although the gastric antrum is commonly affected and can cause gastric outlet obstruction.
10. Radiation gastritis: Small doses of radiation (up to 1500 R) cause reversible mucosal damage, whereas higher radiation doses cause irreversible damage with atrophy and ischemic-related ulceration.
Sex: The male-to-female ratio is 1:1 in the United States and 18:1 in India.
• H. pylori infection is more common with increasing age.
• Duodenal ulcers usually occur in those aged 30-50 years.
• Gastric ulcer prevalence peaks in those aged 50-70 years.
Symptoms of Acid Peptic Disease:1. Pain: Pain is in upper abdomen, which can be sharp, dull, burning, or penetrating. The pain may radiate into the back.
a. Duodenal ulcer pain often occurs hours after meals and at night.
b. The pain of duodenal ulcers is generally episodic; however it can be a chronic one.
c. Pain is often relieved by food in 20-60% of patients with duodenal ulcer.
d. Classic gastric ulcer pain is described as pain occurring shortly after meals.
2. GI bleeding is a common complication of duodenal ulcers and can present in the form of blood in vomitus or stool.
3. There may be bloating, belching, or symptoms suggestive of gastroesophageal reflux.
4. Symptoms consistent with bleeding or anemia (fatigue, dyspnea) may manifest.
5. Recurrent vomiting.
Laboratory:A. Noninvasive tests:
1. H. pylori fecal antigen test: This is quick and extremely accurate test with a sensitivity of 89-98% and specificity of more than 90% in diagnosing the infection or to document eradication. To assess for eradication of H. pylori, stool antigen should be checked only after 8 weeks of completion of therapy. This test is approved by the FDA.
2. Carbon 13 urea breath test: UBT is based on the detection of the products created when urea is split by the organism. This test has a sensitivity of 90-95%. It can be used to diagnose infection, but it is more often used to evaluate the success of treatment of H pylori infection. UBT should be performed 4 weeks after H pylori eradication to prevent false-negative results.
3. H. pylori serology: It has a high (>90%) specificity and sensitivity. It is useful for detecting a newly infected patient. It is of limited value for determining eradication of H pylori because positive results cannot be used to differentiate between past exposure and active infection.
B. Imaging Studies:
• Double-contrast barium study: It is useful in diagnosing a typical gastric ulcer. It is more than 90% sensitive in the hand of an experienced radiologist.
C. Esophagogastroduodenoscopy (EGD): Upper GI endoscopy is often necessary in patients with symptoms of peptic ulcer disease to view the condition of the mucosal lining of the stomach and duodenum and to obtain biopsy specimens from the gastric antrum. EGD is the most sensitive test to detect gastric and duodenal ulcers. It has a sensitivity of greater than 95%. It is diagnostic as well as therapeutic in many ulcer patients.
(Peptic Ulcer disease):
Treatment of Heartburn
Treatment of H. pylori infection: H. pylori infection is not easily cured and requires a multidrug therapy. The first-line treatment to eradicate H pylori is triple therapies. Quadruple therapies are recommended as second-line treatment when triple therapies fail to eradicate H pylori. The accepted definition of a cure is that no evidence of H. pylori after 4 or more weeks of ending the therapy. The therapy should not be administered if if the patient does not have a confirmed infection.
• Triple therapy for adult (Duration of therapy is 14 days):
Lansoprazole (Prevacid) 30 mg or omeprazole (Prilosec) 20 mg or RBC (Tritec) 400 mg twice daily, plus
Clarithromycin (Biaxin) 500 mg twice daily, plus
Amoxicillin (Mox) 1000 mg or metronidazole (Flagyl) 500 mg twice daily
• Quadruple therapy for adult (Duration of therapy is 14 days) :
o Lansoprazole (Prevacid) 30 mg or omeprazole (Prilosec) 20 mg twice daily, plus
o Tetracycline HCl (Resteclin®) 500 mg four times daily, plus
o Bismuth subsalicylate 120 mg four times daily, plus
o Metronidazole (Flagyl) 500 mg thrice daily
• Treatment of H pylori infection in children: Eradication rates in children were reported to be as high as 96% with alternative eradication regimens that include amoxicillin, bismuth, and metronidazole. Children younger than 16 years should not receive salicylate-containing compounds because of the risk of Reye syndrome.
Treatment of NSAID induced PUD:• Discontinuation of NSAIDs is paramount, if it is clinically feasible.
• Treat H. pylori infection, if present.
• If NSAIDs cannot be stopped, change it to a COX-2 selective inhibitors (Celecoxib).
Commonly used medications for acidity:Sucralfate (Carafate): Binds with positively charged proteins in exudates and forms a viscous adhesive substance that protects the GI lining against pepsin, peptic acid, and bile salts. Sucralfate is the primary agent for prophylaxis in stress gastritis. Dose is 1 g four times daily.
Antacids (Digene): Used for general prophylaxis. Antacids containing Aluminum and magnesium hydroxide, magnesia and alumina can help relieve symptoms of gastritis by neutralizing gastric acid. Aluminum ions inhibit gastric emptying. Magnesium/aluminum antacid mixtures are used to avoid bowel function changes. Dose is 5-15 mL oral suspension or 650 mg to 1.3 g tab four times daily.
Nizatidine (Axid): Competitively inhibits histamine at H2 receptors of gastric parietal cells, resulting in reduced gastric acid secretion, gastric volume and reduced hydrogen concentrations. Dose is 150 mg twice daily.
Ranitidine (Zantac, Rantac): Competitively inhibits histamine at the H2 receptors of gastric parietal cells, resulting in reduced gastric acid secretion, gastric volume and reduced hydrogen concentrations. Dose is 150 mg twice daily.
Omeprazole (Prilosec): Decreases gastric acid secretion by inhibiting the parietal cell H+/K+ -ATP pump. Dose is 20 twice daily.
Lansoprazole (Prevacid): Decreases gastric acid secretion by inhibiting the parietal cell H+/K+ -ATP pump. Dose is 30 mg twice daily.
Rabeprazole (Aciphex): Decreases gastric acid secretion by inhibiting the parietal cell H+/K+ -ATP pump. Dose is 30 mg twice daily.
Pentoprazole (Protonix): Decreases gastric acid secretion by inhibiting the parietal cell H+/K+ -ATP pump. Dose is 40 mg twice daily.
Osomeprazole (Nexium): Inhibits gastric acid secretion by inhibiting H+/K+ -ATPase enzyme system at secretory surface of gastric parietal cells. Dose is 20-40 mg.
Food to avoid in Heartburn (Peptic Ulcer Disease):1. Almost all sour tasted fruits, lemons, tomatoes etc.
2. Curd, fermented items like pickles, salty, oily, spicy food.
3. Overcooked Foods.
4. Cheese items and junk foods.
5. Carbonated Soft drinks, tea, coffee etc.
6. Smoking and alcoholism must be totally avoided.
Food to be included in diet in Heartburn (Peptic Ulcer Disease):1. Sweet in little quantity. As Indian traditionally serves sweet along with the food, the Indian food is supposed to be a balanced diet.
2. Coconut, ripened mango, wood apple and pomegranate.
3. Salads, Carrot leaves, celery leaves, curry leaves, sweet potatoes and beet root.
4. Water melon and cucumber.
5. Acidifying vegetables include corn, lentils, olives, squash, beans, lentils, soy, rice milk and almond milk.
6. Nuts that are acidifying include peanuts, cashews, pecans, walnuts and legumes.
7. Acidifying fruits include cranberries, blueberries, currants, plums and prunes.
Home Remedies for Heartburn (Peptic Ulcer Disease):1. Holy basil (tulsi): Consuming few leaves of tulsi (2-3) leaves anytime gives relief from acidity.
2. Drinking water in the early morning controls acidity, as water is a good neutralizer for acid.
3. Pranayama: Deep breathing the right way until body feels relaxed or for about ten minutes is a good home remedy.
4. Indian gooseberry (Amla): One table spoon Amla with one table spoon haritaki (chebulic myroblan) is best acid pacifier.
5. Turmeric (Haridra): This is well known healer. It heals the lining of the stomach damaged by excess acid.
6. Bitter guard (Karella): This is one of the best acid pacifiers.
7. Cumin seeds (Jeera): The cumin seeds boiled in a glass of water are used in treating dyspepsia.
8. Cardamom (Elaichi): Cardamom is an effective in acidity.
9. Clove (Long): Sucking a piece of clove is excellent in treating acidity and irritability in the stomach.
10. Fennel (Saunf): Fennel seeds are effective in dyspepsia. It is a mild purgative, used in digestive and acidity complaints in infants and young children.
11. Fenugreek (Methi): Methi leaves are considered to be a very good in dyspepsia.
12. Juice of raw spinach also helps to reduce acidity.
13. Suck a small piece of jiggery gradually in mouth till acidity disappears.
14. Carrot juice gives relief from acidity.
15. Mint juice or mint capsules containing peppermint oil after meal are also a good for treating acidity. It also reduces gas formation.
16. Herbal tea containing spearmint (pudina) and liquorice (mulethi)
17. Elevate the head of your bed to reduce the chance of heartburn at night. The height of the elevation must be at least 6 to 8 inches to be at least minimally effective to stop the backflow of gastric fluids.
Myths and Facts about Heartburn (Peptic ulcer disease):Myth: Eating habits have nothing to do with acidity.
Fact: Chewing food well and taking frequent small meal decreases acidity.
Myth: Drinking fruit juices helps in acidity.
Fact: Juices especially sour one aggravate acidity.
Myth: I can get heartburn relief with lots of antacids.
Fact: Constantly taking antacids can cause demineralization of bone, promoting for fractures.
Myth: Eating Spicy Foods Cause an Ulcer.
Fact: Spicy food can increase the acidity in some, but it is not the cause of Ulcer.
Myth: Heartburn is a heart condition.
Fact: Heartburn has nothing to do with heart diseases.
Myth: A glass of milk is a good home remedy to help reduce the symptoms of acid reflux.
Fact: Milk, especially cold milk seem to soothe the symptoms initially, but later it causes an increase in the production of acid.
Myth: Drinking wine, beer, or another alcoholic beverage before bed is a great way to reduce stress and relieve nighttime acid reflux.
Fact: Alcohol at night increases the likelihood of acid reflux.
Myth: A bedtime snack will help soothe my stomach.
Fact: Foods need to be digested and digestion causes the stomach to produce acid.
Myth: Smoking a cigarette helps relieve heartburn.
Fact: Smoking increases heartburn and reflux.