Ulcers Diagnosis

  • Diagnosis

    An ulcer within the digestive tract, also known as a peptic ulcer, is a sore in the lining of the stomach or the upper portion of the small intestine (duodenum) Figure 01, Figure 02.During digestion, the stomach secretes juices that aid in digestion. These fluids are as caustic as car battery acid. Normally, other substances produced in the body protect the lining of the stomach from its highly acidic environment. Ulcers develop when aggressive factors overwhelm protective mechanisms.

    Click to enlarge: Anatomy of the Digestive System

    Figure 01. Anatomy of the Digestive System

    Click to enlarge: Stomach and Duodenal Ulcers

    Figure 02. Stomach and Duodenal Ulcers

    Until recently, doctors thought peptic ulcers resulted from stress and diet. Now they know many ulcers are due to a Helicobacter pylori (H. pylori) bacterial infection.

    About 90% of duodenal ulcer and 70% of stomach ulcer patients are infected with H. pylori bacteria.

    Many people are unaware that most ulcers are an infectious disease, and that hand washing is a means of protecting against it.Like many other bacteria, H. pylori can be passed from person to person, probably through ingestion of bacteria that have been eliminated from another human body through either vomit or stools. Eating food touched by someone who has not washed his or her hands after a bowel movement may be one way in which the H. pylori passes from one person to another.

    Stomach ulcers (gastric ulcers) are also connected to the use of pain medications called nonsteroidal anti-inflamatory drugs (NSAIDs) such as aspirin or ibuprofen (Advil, Motrin, and Aleve).Most NSAIDs are over-the-counter drugs that are taken for fever, aches, and pains. Prescription strength NSAIDs are used to treat arthritis. NSAIDs contribute to the formation of stomach ulcers because they damage the three defenses that the stomach has against digestive juices. The defenses include: the stomach’s mucus lining, which acts as a physical barrier to the acid, the bicarbonate (a component of the baking soda) produced by the stomach that counteracts (neutralizes) the acid; and the blood circulation to the stomach lining, which promotes cell repair.

    Most peptic ulcers result from an infection with H. pylori bacteria or the use of nonsteroidal anti-inflammatory drugs (NSAIDs). Both bacterial infection and NSAIDs interfere with the normal balance of digestive fluids. The fluids include acid, enzymes such as pepsin, and protective mechanisms that guard the lining of the stomach from the strong acids. An ulcer may develop when the fluids become unbalanced. If the fluid becomes too acidic (either through overproduction or the protective mechanisms are lost), it irritates the stomach lining resulting in inflammation, erosions and ultimate development of ulcers.

    NSAIDs interfere with protective elements normally present in the stomach. Because NSAIDs such as aspirin and ibuprofen interfere with the stomach’s defense mechanisms against acid and pepsin (the main enzyme in gastric juice), the risk of ulcer increases when a person takes these drugs. The stomach protects itself against the strong acid and enzymes needed to digest food in three ways: a mucus lining that coats the inside of the stomach, the production of bicarbonate to neutralize acid, and blood flow to the stomach that promotes cell repair. Ulcers develop when damage to these mechanisms exceeds the stomach's ability to repair itself.

    Approximately 70% to 90% of all peptic ulcers are caused by H. pylori, but doctors are not sure how these bacteria cause ulcers. The H. pylori bacteria have a spiral shape that may allow them to burrow into the stomach lining and damage it. H. Pylori bacteria produce a chemical that changes the acidity (pH) that surrounds them and causes inflammation.

    H. pylori infection is common in developing countries and among people older than age 60 in the U.S., about half of whom harbor the bacteria. However, most people who are infected with the bacteria do not develop stomach ulcers. Scientists do not yet understand why H. pylori cause ulcers to develop in some individuals but not in others. Theories currently being studied include characteristics of the infected person, including genetics and diet, and the characteristics of different types of H. pylori.

    Physical stress, such as surgery or disease, can cause the development of an ulcer. Emotional stress may aggravate the lining of the stomach, but it does not cause ulcers. However, it may serve as a trigger. Radiation treatment, alcohol abuse, and physical trauma, such as major surgery or severe burns, also can lead to ulcer development.

    The genetic disorder Zollinger-Ellison syndrome (ZES) is responsible for some ulcers. Zollinger-Ellison syndrome is a rare disorder in which tumors secrete large amounts of the hormone gastrin. This hormone causes the stomach to produce excess acid which attack the lining of the stomach and cause ulcers. These ulcers tend to be more painful and are harder to treat than other stomach ulcers. Scientists think that an abnormal tumor suppressor gene causes Zollinger-Ellison syndrome. The disease most often occurs in people between the ages of 30 and 60 years of age.

    Ulcers cause abdominal pain that often starts one to three hours after finishing a meal. The pain may awaken you from sleep, and it may travel from your stomach to your back. Eating something or taking an antacid may alleviate the discomfort. But some days these remedies will work, and on others, they may not. Somewhere between 30% to 80% of ulcer patients complain that the pain wakes them from sleep, especially if they have eaten a bedtime snack. The pain may last for a few minutes or a couple of hours.

    Ulcer symptoms tend to come and go. You may feel the pain regularly for weeks or months, then it will subside for a while, only to start back up again.

    Other symptoms include bloating, belching, nausea, vomiting, blood in the stool, decreased appetite, unexplained weight loss, or pain in the upper back. These symptoms occur less frequently than gnawing pain in the upper abdomen. Because ulcers sometimes bleed, you may notice blood in the stool. The blood will cause your stool to be very dark, and have a tar-like appearance.

    Sometimes, peptic ulcers do not produce digestive-tract symptoms. Ulcers caused by NSAIDs often do not cause any discomfort or noticeable changes. But these ulcers may bleed. If this occurs, the only symptoms you may experience are fatigue or shortness of breath. Talk to your doctor if you take NSAIDs and develop these symptoms.

    The H. pylori infection can be passed between people. Table 01. It appears H. pylori spreads through ingestion of bacteria that has been eliminated from another human body, most likely through vomit. However, it can also be transmitted through stool. Eating food touched by someone who has not washed his or her hands after a bowel movement may be one way in which H. pylori passes from one person to another.

    Approximately 20% of young adults in the U.S. are infected, as are 50% of people older than age 60. Poverty increases the risk of infection. This may be due to poorer sanitation and crowded living conditions. Close person-to-person contact seems to increase the spread of H. pylori. People typically pick up the bacteria during childhood.

    H. pylori infection occurs more frequently in developing countries. About 80% of those living in developing counties harbor the bacteria.

    Table 1.  Risk Factors for H.pylori Bacterial Infection

    Starting life in a developing country
    Being born before 1950
    Low socioeconomic status
    Sharing a house with a baby
    Living in close contact with many family members
    Exposure to stomach contents (vomit) of someone with the infection
    Drinking three or more cups of coffee per day

    Taking traditional NSAIDs, which include aspirin, ibuprofen, and many other over-the-counter pain relievers, increases the risk of ulcers. As many as 20 million Americans regularly take NSAIDs. Between 15% and 25% of these people develop ulcers visible during an examination of the gastrointestinal tract. Drinking alcohol or smoking adds to the danger. Doctors believe that a new type of NSAID, called a COX-2 inhibitor, is less likely to cause ulcers than older types of NSAIDs because it does not damage the protective mechanisms of the stomach.

    Nonsteroidal anti-inflammatory drugs pose a greater risk for older people, those with a history of ulcers, and for patients using steroids or anticoagulant drugs. Among chronic users of NSAIDs, the prevalence of ulcer is 15% to 30%. Development of ulcers in these patients is related to the dose and potency of the drug. Between 6% and 12% of patients who were started on chronic NSAID therapy developed gastric ulcer after eight weeks of treatment. Among the elderly, about 30% of peptic ulcers are caused by NSAIDs. Use of NSAIDs either alone or in combination with steroids and anticoagulant drugs increases life-threatening complications of peptic ulcers.

    Having a close relative who has peptic ulcer disease increases your risk.

    Twice as many African-Americans and Hispanics develop the condition in comparison to Caucasians.

    Patients complaining of stomach ulcer symptoms should receive an H. pylori test. A breath test or blood test can determine if you have H. pylori. Both tests may be done in a doctor's office. For the breath test, you fast for several hours, ingest a special test substance, and breathe into a container. The blood test detects a substance that your body produces in response to bacteria (antibodies). However, if you have recently been treated for an ulcer, this test may not be effective for you. The antibodies from the previous ulcer may linger for months after drug treatment, so if you have recently received treatment for an ulcer, having this test is likely to result detect antibodies to a former infection that is no longer present.

    An upper gastrointestinal (GI) tract x-ray study can help identify whether an ulcer exists and where it is located. You will drink a chalky substance called barium to line the digestive tract and make it visible on film. X-rays are then taken. The images show the outline of the stomach and upper intestine. Active ulcers and scarring from previous ulcers will look different from normal tissue.

    An endoscopy provides doctors with the most complete information about your ulcer. During the exam, the doctor inserts a long, thin instrument with a tiny camera on the end through your mouth into your stomach and into the duodenum. The tool lights the area and allows the doctor to view the ulcer and the condition of the lining, and to take samples for laboratory analysis. For the procedure your throat is numbed by spraying a topical anaesthetic and you will usually receive a sedative and a pain medication. The procedure can be uncomfortable although minimally, and is expensive. But endoscopy provides a direct visualization of the lining of the food pipe (esophagus), the stomach and the duodenum. An endoscopy may be done after treatment to assess the therapy's effectiveness for healing of the ulcer if your doctor thinks it is necessary. In case you are experiencing problem with swallowing, vomiting blood, losing weight or losing blood in stool endoscopy is the diagnostic method of choice.

    Blood tests and testing a stool specimen for blood can help detect if your ulcer is bleeding. A complete blood count is used to assess for anemia. Blood in the stool is often not visible. Hidden blood will show up by testing a small stool specimen.

    Even though the exact mechanism of how H. pylori is spread remains unknown, there are several things you can do to lower your risk of ulcer.

    • Wash your hands before fixing food or eating.
    • Drink water from a clean source.
    • Eat food prepared under sanitary conditions.
    • Drink fewer than three cups of coffee per day.

    Most ulcers caused by nonsteroidal anti-inflammatory drugs can be prevented by taking an additional medication, taking only a low dose of an NSAID or by switching to a different drug. Your doctor might order a second medication, such as misoprostol (Cytotec) to take with an NSAID, which can lower your risk of developing an ulcer. Taking the lowest NSAID dosage that provides relief helps decrease the chance of developing an ulcer. Discontinue the drugs as soon as possible. Some people find other medications provide similar relief. Discuss the risks and alternatives with your doctor.

  • Prevention and Screening

    Even though the exact mechanism of how H. pylori is spread remains unknown, there are several things you can do to lower your risk of ulcer.

    • Wash your hands before fixing food or eating.
    • Drink water from a clean source.
    • Eat food prepared under sanitary conditions.
    • Drink fewer than three cups of coffee per day.

    Most ulcers caused by nonsteroidal anti-inflammatory drugs can be prevented by taking an additional medication, taking only a low dose of an NSAID or by switching to a different drug. Your doctor might order a second medication, such as misoprostol (Cytotec) to take with an NSAID, which can lower your risk of developing an ulcer. Taking the lowest NSAID dosage that provides relief helps decrease the chance of developing an ulcer. Discontinue the drugs as soon as possible. Some people find other medications provide similar relief. Discuss the risks and alternatives with your doctor.

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