Peptic-Ulcer Disease: Diagnostic Treatment and Optimal Management in the Elderly
The term ''peptic ulcer'' is used for an ulcer in any part of the GI tract that is exposed to secretions of gastric acid. Peptic ulcers are usually found in the stomach (gastric ulcers) and in the first part of the duodenum (duodenal ulcers) but they also occur in the lower part of the esophagus and in the distal part of the duodenum.
Peptic ulcers develop when there is a breakdown of the natural balance between the aggressive attacking factors and defensive factors of the mucosa.
The most important destructive factors are the hydrochloric acid and pepsin secreted by the stomach. If duodenal reflux occurs such constituents as bile. pancreatic enzymes and lysolecithin may also contribute to ulceration. External factors such as nicotine and tars from tobacco, analgesics such as aspirin, and the newer non-steroidal anti-inflammatory drugs (NSAIDS) may also be important contributory factors in particular populations. There is also some evidence to suggest that psychological factors play some part stressed individuals who worry a great deal typical patients are busy,
The differences between Gastric And Duodenal Ulcers
Peptic ulcers are often regarded as one clinical entity, but it is increasingly being recognized that gastric and duodenal ulcers have different etiologies, so some aspects of their treatment also vary. In both types of epidemiological findings strongly suggest that environmental factors are partly responsible for the disorder but so far none have been truly isolated. Both types of ulcer are more common in people with blood group O.
The commonest symptom of a peptic ulcer is epigastric pain. This is pair in the upper central abdomen, usually described as a burning or gnawing sensation, it comes and goes and is usually related to meals.
- A gastric ulcer causes pain shortly after eating.
- A duodenal ulcer causes pain between meals and is usually relieved by eating Characteristically, sufferers complain of pain waking them in the early hours of the morning.
Other symptoms may be
- Loss of weight.
- Nausea and distension.
The nausea may prevent a patient with a duodenal ulcer from eating the very foods that would bring relief from the pain. In some cases an ulcer may be without t symptoms until a complication such as bleeding or perforation occurs. If an ulcer bleeds slowly, melaena (black, tarry stools) results and the patient will often be anemic. If there is a large, sudden bleeding the patient usually vomits blood (hematemesis).
Methods Of Investigation
The standard method of investigation has been the giving of a barium meal: the sufferer swallows a radio-opaque material and its progress through the stomach is observed by X-ray). In many hospitals fibre-optic endoscopy has superseded this. By this means a fine tube is introduced into a patient's stomach so that the surface of the stomach and duodenum can be observed directly. It is also possible to measure the secretion of gastric acid after the injection of the drug Penta gastrin, which stimulates the secretion. It is important to exclude gastric cancer as a cause of the problems: the secretion of acid is usually nil or low in patients with gastric cancer.
Once a diagnosis has been confirmed treatment can be started and this may involve medical or surgical procedures.
The Medical Treatment Of Peptic Ulcers
The objectives of treating any peptic ulcer are to:
1. relieve the symptoms
2. heal the ulcer
3. prevent its recurrence
4. prevent complications
In uncomplicated cases it is often relatively easy to relieve the symptoms and sometimes patients recover without any medical treatment. However, it is not so easy to prevent an ulcer's recurrence and many patients have frequent relapses and remissions (though these are often mild and easily treated) whether or not they undergo treatment. It has been said that patients with duodenal ulcers have a relapse rate as high as 80% even with treatment.
If an ulcer has perforated the gut wall or if massive bleeding occurs, then emergency surgery may be necessary. A patient who has not responded to medical treatment or whose condition is suspected of being malignant may also need surgery.
The traditional treatment for all peptic ulcers was always: rest, relaxation, regular meals, and to some extent this still holds. However there are now much more powerful drugs that suppress the production of acid. The principles of current treatment are therefore:
- Rest, both physical and mental.
- Drugs- antacids and secretory inhibitors.
- Stopping smoking.
- Attention to diet.
Rest and relaxation
Patients often report an improvement in the symptoms if the pace of life is slowed down. So it may be necessary to cut down on both work and social activity to ensure they are both mentally and physically relaxed: patients often need psychological support to achieve this.
Rest in bed has been shown to be beneficial for patients with gastric ulcers (but not for those with duodenal ulcers), although modern treatment methods should make it unnecessary to recommend this in most cases.
The best drugs are those that block H2 receptors in the mucosa and therefore reduce the secretion of acid: they relieve symptoms and may promote healing. Examples of such drugs are Cimetidine and Ranitidine. Because of their effectiveness in treating peptic ulcers these drugs often replace surgery as a treatment for duodenal ulcers. Patients with gastric ulcers often do not secrete large amounts of acid but a reduction of the secretion is still an effective treatment for some therefore-in any clinicians believe that H₂ blockers still have a place in the treatment of gastric ulcers.
Suspensions such as aluminum hydroxide, magnesium hydroxide and trisilicate have been used for many years and usually relieve pain.
Smoking should be discouraged; patients with duodenal ulcers should definitely stop smoking as it has been demonstrated that healing then occurs more quickly.
Learn more about the Optimal Nutritional Care and Dietary Treatment of Peptic Ulcer in the Elderly.
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