What is an ulcer?

A peptic ulcer is a localized lesion affecting the mucous membrane of the digestive system exposed to the action of the stomach's acid secretions. The most frequent location of ulcers is in the stomach and duodenum.

 

However, ulcers can also appear in other anatomical regions:

• in the esophagus, in case of acid or alkaline reflux from the stomach into the esophagus itself;
• in the jejunum, after surgery that has removed the lower half of the stomach and duodenum;
• in Zollinger-Ellison syndrome (an often familial tumor of the endocrine system);
• in Meckel's diverticulum (a diverticulum of the small intestine), due to the presence of gastric mucosa when, normally, it should not be present;

What are the causes of gastric ulcers?

The gastric secretion of hydrochloric acid and pepsin plays a fundamental role in the appearance of ulcers. Indeed, it has been shown that gastric ulcers do not occur in the case of achlorhydria (absence of acid secretion). The gastric and duodenal mucous membranes, under normal conditions, are very resistant to the action of acid-peptic secretion. The appearance of an ulcer in the stomach and duodenum is therefore considered to be the result of an imbalance between the factors aggressive to the mucosa (acid and pepsin, gastrointestinal substances, bacteria, etc.) and the defensive factors (mucus and bicarbonate secretion, blood flow in the mucosa, cell renewal), which participate in the formation of the "mucosal barrier". On the other hand, the mucosa of other parts of the digestive system is particularly sensitive to gastric secretions. Acid reflux into the lower part of the esophagus in subjects with cardia incontinence (the valve separating the esophagus from the stomach), or the passage of acidic chyme into the jejunum following surgical removal of part of the stomach and duodenum, can indeed induce the appearance of peptic ulcers. However, these last two forms have a very low incidence, which is why the term peptic ulcer is commonly used to designate peptic ulcer disease, which accounts for 98% of all ulcerative diseases.

 

What are the treatments for gastric ulcers?

Medical therapy to treat gastric ulcers

It is also important to eliminate the factors that lead to an imbalance between the aggressive and defensive factors of the gastroduodenal mucosa. It therefore becomes important to combat - if associated with it - infection by H. Pylori and to avoid taking gastrointestinal medications unless absolutely necessary. The diet should be controlled, reducing the consumption of foods containing xanthines (coffee, tea, coca-cola) and alcohol.  

Essentially, the medications used are of 3 types:

• Inhibitors of gastric acid secretion, i.e. histamine H2 receptor antagonists and today proton pump inhibitors;
• Drugs that buffer excess gastric acidity (antacids);
• Drugs that act by directly protecting the mucosa (sucralfate);

Although peptic ulcers can heal quickly with these medications, recurrences are frequent if treatment is interrupted, reaching up to 80% of recurrences at one year.

 

The use of gastric acid secretion inhibitors (H2 antagonists and proton pump inhibitors) at low doses for prolonged periods has proven effective in reducing the frequency of recurrences and the incidence of complications. Complete treatment of gastric ulcers must necessarily include the eradication of infection, with the combination of specific antibiotics.

 

When the infection is eradicated, the recurrence of ulcers, both duodenal and gastric, is less than 2% after one year. At the same time, complications of gastric pathology, notably hemorrhages, are also reduced.

 

Surgical treatment of gastric ulcers

Surgical treatment of gastric ulcers is now mainly reserved for complications. Perforation, whether gastric or duodenal, is the main indication for surgery.

 

Gastric juice spills into the peritoneal cavity, causing immediate and violent stimulation of the nerve endings of the peritoneum, with pain that occurs acutely, of a piercing type in the epigastrium, then radiating throughout the abdomen. The picture is not always preceded by the classic symptoms of the ulcer.

 

Peritonitis due to perforation is a surgical emergency: it is essential to carefully wash the entire abdominal cavity and suture the perforation point. Surgical access, when possible, should be done by laparoscopy: this allows inspection of all the compartments of the abdominal cavity, and allows for correct washing and drainage. Suturing the ulcer breach can be difficult, and sometimes requires conversion to laparotomy. Again, if this cannot be done, it may be necessary to resort to resection of the gastric antrum.

 

What are the possible complications of gastric ulcers?

Bleeding can occur acutely, resulting in vomiting of blood (hematemesis) and the passage of black stools (melena). The acute picture is generally dominated by signs of shock, with acute hemodynamic decompensation, and may present the characteristics of a true emergency.

 

In addition to medical treatment aimed at supporting circulation and vital functions, it is essential to check the origin of the hemorrhage and remedy it. This can be achieved in most cases by endoscopy. During the endoscopic examination, it is possible to inject medications that allow control of the bleeding. It is only in the case of hemorrhages refractory to endoscopic treatment that it may be necessary to resort to surgery, which generally consists of removing the part of the organ that is the site of the ulcer (gastric resection).

 

Very rarely today, we see the appearance of duodenal stenosis, due to the repeated scarring of recurrent ulcerative lesions. Relatively frequent until 30 years ago, with today's medications stenoses have become very rare. Their treatment mainly consists of a resection of the gastric antrum or, in the case of very elderly patients or those with serious associated pathologies, in the creation of a bypass allowing for feeding.

 

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