The development of the ulcer

Peptic ulcer is universally present all over the world, incidence varying from region to region, country to country. Peptic ulcer comprises a group of ulcerative disorders of the upper part of gastrointestinal tract involving mainly the stomach and duodenum.

The ulcer can occur only in the presence of acid and pepsin. For the development of the ulcer there has to be disturbance of balance between gastric acid secretions and the factors which comprise mucosal defense. It is found in all those parts of the digestive tract where there is constant exposure to acid-pepsin or on places where there is presence of gastric mucosa i.e. lower end of oesophagus.

Incidence: It is difficult to define the exact incidence of the disease since it is universally present. Its distribution is global and no particular race or community is exempt. About one in 10 people are supposed to suffer from peptic ulcer like symptoms at sometime or another. Age and Sex: All ages are known to be effected by ulcer but on average the onset occurs in the second or third decades going up to fourth or fifth decade. Both sexes are equally affected. Duodenal ulcers are more common in men than in women.

Women have relatively less incidence of the disease especially during the reproductive years of life and this immunity declines with the start of menopause. Probably female hormones are acting as protective factors in women. Social class: Duodenal ulcer occurs with greater frequency than gastric ulcer in higher social grade. But professional and business classes, executives who are more ambitious and always in the rat race to reach the top, are the people who are work conscious, meticulous and are always on the go. Such people pay their price becoming susceptible and get ulcers.

It is the make up and temperament of the individual which is an important factor. Familial and genetic factors: The incidence of peptic ulcer in first degree relatives of ulcer patients is three times as high as in general population. An increased incidence of HLA-B5 antigen and elevated serum pepsinogen levels are seen in patients of duodenal ulcer. Diet: It has an important bearing on the production of ulcer. The incidence of ulcer in those who take spicy food is very high. Similarly people whose diet is rich in carbohydrates but poor in proteins are prone to develop ulcers.

The temperature of food eaten also is important since food or beverages taken very hot act as thermal irritants. Tobacco and alcohol have an important bearing on the problem. Smokers have a higher incidence of ulcer and have higher mortality from the disease. Ulcers in smokers take longer time to heal. Alcohol especially of high spirit content not only produces direct inflammation and injury to gastric mucosa but subsequently increases gastric acid secretion, thus increasing proneness to ulcer formation.

Blood groups: A relationship between blood groups and ulcers has been established. The risk of duodenal ulcer in blood group O subjects as compared to other blood groups is higher. Association of Peptic ulcer and other diseases: Certain diseases like chronic gastritis, hiatus hernia, chronic emphysema with or without cor-pulmonale, hyperparathyroidism, biliary cirrhosis run higher risk of developing gastric or duodenal ulcer. Symptoms: The onset of the disease is gradual spread over a period of months.

The earliest symptom is pain which varies in intensity from mild to severe, having gnawing or burning character. In gastric ulcer pattern is FOOD-PAIN-RELIEF. Pain comes 15 to 2 hrs after meals depending on the site of ulcer. The pain disappears after about an hour and is relived by vomiting. In duodenal ulcer the pattern is PAIN-FOOD-RELIEF-PAIN. Ingestion of food brings part of neutralization of gastric acid secretions. Complications of ulcer: • Pyloric obstruction • Perforation of ulcer which produces picture of acute peritonitis • Haemorrhage • Malignancy Summary:

Thus a number of factors ranging from injury to gastric mucosa, lowered mucosal resistance, dietary and nutritional factors, heredity emotions, gastric acid secretions, defective mucosal resistance and gastric hormones play there role in the role in the pathogenesis of peptic ulcer. In short it is ‘acid pepsin’ versus ‘mucosal resistance’. Management of an ulcer patient: An ideal approach in the management of a case of peptic ulcer is to give relief from the discomfort of pain and to promote quick healing of an ulcer with an eye towards prevention of recurrence and complications.

Guide lines for an ulcer patient: • Adopt a positive attitude towards life • Keep your cool • Take adequate rest • Have regular feeds (small and frequent) • Take small feeds of mil at regular intervals. It shall soothe your stomach • Avoid smoking, alcohol, carbonated drinks (colas), strong tea and coffee • Avoid fried and spicy foods • Diet should be soft and bland • Avoid taking aspirin and other drugs of NSAIDSs groups • Keep off tension • Avoid raw undercooked or fibrous vegetables, fruits with skin. Gravies, cakes, pastries be avoided. Prefer refined foods, well cooked and soft vegetables.

• Drugs include antacids (sodium bicarbonate), antisecretory drugs (simetidine 200mgs- one tablet thrice a day and 2 at bed time for 6 weeks) and antispasmodics (propantheline, dose 15mg thrice a day and at bed time) Reference: • Robbins, S. L; basic pathology, w. b. Saunders Co. Philadelphia and London • Malme, F. S : Handbook of medical emergencies, 3rd edition, St. Louis 1997 • Swashm M: Hutchison’s clinical methods, twentieth edition, W. B. Saunders company, London 1997 • S. N. Khosla, Medicine For Dental students, Rohtak, India 2007 • Clark M : clinical methods, 4th edition, Philadelphia and London

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