What is a peptic ulcer?

This is an sore or an ulcer in the upper part of the digestive system which includes the stomach and the duodenum. It can result in significant pain in the abdomen as well as runs the risk of bleeding as well. 

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What causes peptic ulcers?

Ulcers in the digestive tract are either cause by excess acid or due to the lining of the stomach/duodenum becoming weaker. This can be cause by the following:

  • H.pylori infection- this is a type of bacteria that commonly grows in the digestive tract and is the commonest cause of peptic ulcers. Not all patients with H.pylori develop ulcers but some can. The bacteria causes an increase in the amount of acid in the digestive tract, leading to inflammation of its lining and can breakdown the protective inner layer of the stomach/duodenum. 
  • NSAIDs such as ibuprofen which can affect the protective mucosal layer of the digestive tract
  • May run in the family
  • Smoking
  • Excess alcohol intake
  • Stress

What are the symptoms of peptic ulcer disease?

  • Pain in the upper abdomen
  • Early satiety
  • Belching
  • Bloating soon after eating
  • Heartburn
  • Feeling of sickness
  • Vomiting in severe cases which can also have blood in it
  • Blood in the stool which usually appears very dark, also known as tarry/black
  • Duodenal ulcers usually causes pain after eating

How are peptic ulcers diagnosed?

The following investigations can be performed when peptic ulcers are suspected:

  • Endoscopy is a thin tube with a camera that can be inserted into the stomach and duodenum via the mouth. This allows to directly visualise the inside of the oesophagus, stomach and duodenum. If an ulcer is identified on endoscopy a sample can be taken from the ulcer to test for H.pylori or any abnormal cells. 
  • Barium swallow can be performed in which the patient is made to drink a dye and a series of x-rays are performed. This is usually done when the patient has symptoms of vomiting because of an ulcer. 
  • Test for H-pylori which can either be done with a breath test by your GP or via endoscopy. 

What are the treatment options?

Most ulcers can be treated by medication as long as they are uncomplicated. Treatment of the ulcer is dependent on the cause.

  • If H.pylori is the cause this can be treated with a combination of medications including a course of antibiotics and medication to supress acid on the stomach also known as a proton pump inhibitor
  • If the patient tests negative for H.pylori then acid suppression alone can be used to treat the ulcer. This may need to be taken for at least 4-6 weeks, possibly even longer. 
  • Stop all NSAID medications
  • Lifestyle changes including stopping smoking and reduce alcohol intake.

What are the consequences of not undergoing treatment?

If patients choose to not undergo the above treatment complications from ulcers can develop including:

  • Bleeding from the ulcer. This will present as vomiting with blood or blood in the stool (black stool). At times patients can be very unwell from this and may need admission to hospital due to this. When the ulcer is actively bleeding an emergency endoscopy may need to be performed to treat the bleeding ulcer by application of clips, injecting adrenaline into the ulcer or other materials to stop the bleeding. If endoscopy does not work to stop the bleeding then surgery or embolization (inserting a coil into the bleeding blood vessel) may be required. 
  • Perforation of the ulcer is when the ulcer erodes through the entire thickness of the digestive tract.  This can result in the patient becoming very unwell. The symptoms experienced include severe sudden onset abdominal pain, temperature, vomiting and feeling very unwell. The treatment for this generally involved resuscitation and emergency surgery to repair the ulcer. 
  • Obstruction or a blockage from the ulcer is also a known complication but usually occurs when the ulcer has been present for a long time. This is treated with a tube inserted into the stomach via the nose, IV fluids and acid suppression medication. Endoscopy can be used to relieve the blockage but using a balloon to dilate the part of the digestive tract that is blocked. If this does not work, surgery may be required

How is procedure performed?

Surgical intervention may only be needed if the there is evidence of complications of the ulcer such as bleeding, obstruction or perforation and endoscopic management has not been affective. 

 

In the instances of bleeding from an ulcer, this is usually caused when the ulcer erodes into a blood vessel. Initial management should always be attempted by endoscopy. Is this does not work an emergency laparotomy may be needed to be performed. This is when an incision in the middle of the abdomen needs to be made. This is followed by making an incision at the site of the ulcer and inserted deep stitches through the also to stop the bleeding. This is known as underrunning the ulcer. 

 

In the instances of a perforation of an ulcer, a key hole procedure (laparoscopic) or laparotomy (bigger incision) may be performed to suture the ulcer so that digestive contents are no longer leaking into the abdomen.

 

In the instances of an obstruction due to an ulcer, a key hole procedure (laparoscopic) or laparotomy (bigger incision) may be performed to remove the aspect of the digestive tract that is blocked. For example, if there is a gastric ulcer causing a blockage, the lower part of the stomach may be removed. Following this part of the intestine may be needed to be joined back to the stomach to enable bowel continuity.

What are the risks surgery?

  • Infection
  • Pain
  • Intra or post procedure bleeding
  • Damage to other organs within the abdomen including the bowel, liver, stomach etc
  • Bowel perforation
  • Conversion to open surgery
  • Need for endoscopy or return to theatre post-surgery if there is concern of persistent complications
  • Collections and sepsis
  • Leak at the site of joins known as an anastomotic leak leading to collections, infection and possible need for return to theatre
  • Complications related to a prolonged operation/anaesthetic including clots in the legs, lungs, brain or heart.

How long will I be in hospital and what is the recovery period and follow up?

  • Uncomplicated peptic ulcer disease does not necessarily require admission into hospital but requires treatment and investigation as an outpatient and follow
  • Recovery is dependent on the reason for admission. 
  • In the instances of bleeding that is managed by endoscopy admission usually lasts for about 5-7 days. 
  • In the instances where surgery is required for bleeding, obstruction or perforation admission usually lasts about 7-10 days. 
  • Patients are usually kept nil by mouth for the first day or two and then the oral diet is slowly built up from clear fluids eventually to a soft diet on discharge. 
  • A soft diet is recommended for 4 weeks after surgery after which they can return to a normal diets
  • Most patients are sent home with treatment of H.pylori infection and a prolonged course of acid suppression treatment
  • An outpatient follow up endoscopy is usually performed to assess healing of the ulcer which is performed 6-8 weeks after discharge. 
  • Skin clips may be used on the abdominal incisions which will need to be removed 14 days from the day of surgery. 
  • No heavy lifting or strenuous activity for 6 weeks
  • Patients will be followed up 4-6 weeks after surgery

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