Peptic ulcers are chronic ulcers that occur mainly in the stomach and duodenum, but also in the lower esophagus, near the gastro-jejunal anastomosis, and in Meckel’s diverticulum. The formation of these ulcers is related to the digestive action of gastric acid and pepsin, so they are called peptic ulcers. Their pathogenesis is the result of an imbalance between local mucosal damage (ulcerogenic) and mucosal protection (mucosal resistance) factors in the stomach and duodenum. The focus of the pathogenesis of gastric ulcers is the weakening of protective factors, and the focus of the pathogenesis of duodenal ulcers is the enhancement of damaging factors.
Clinical manifestations of peptic ulcers
Chronic course with periodic episodes of disease with alternating periods of exacerbation and remission; rhythmic pain. Rhythmic and cyclic disappears in the presence of complications.
1. Pain. Epigastric pain is the main symptom of peptic ulcer, the nature of pain varies, it can be dull, burning, distension or severe pain, but also can only feel discomfort. Typically, the pain is mild or moderate and persistent, limited in scope, with gastric ulcer located in the middle or to the left of the subxiphoid process, appearing 0.5-2h after meals; duodenal ulcer pain is located in the middle or slightly to the right of the epigastrium, appearing 3-4h after meals, and can be relieved by taking acidulants and eating. There can usually be mild pressure pain in the epigastrium.
2. Other. Digestive symptoms such as epigastric fullness, belching, acid reflux, nausea, vomiting, and loss of appetite.
Complications mainly include: bleeding, perforation, pyloric obstruction, and cancer.
Treatment
The purpose of treatment is to relieve symptoms, promote ulcer healing, and prevent recurrence and complications.
1.Drug treatment
(1) Drugs to reduce damaging factors
①Acid control agents. They can reduce the acidity in the stomach and duodenum, relieve pain and promote ulcer healing, but are rarely used alone.
②Anti-cholinergic drugs. Can resist the vagus nerve and reduce gastric acid secretion, can release vasospasm and improve mucosal blood flow, can relax smooth muscle to delay gastric emptying, which is conducive to prolonging the effect of acidophilus and food neutralization of gastric acid, now rarely used.
③H2 receptor antagonist. Can block the binding of histamine and H2 receptors on the wall cell membrane and inhibit the secretion of gastric acid, such as mecamylamine, ranitidine, etc.
④Proton pump inhibitors. Strongly inhibits the activity of cation pump (H+/K+-ATPase) and blocks H+ from being secreted outside the mural cell body, such as omeprazole, dacrypromine, etc.
(2) Drugs that enhance protective factors combine with proteins on the ulcer surface to form a protective film covering the ulcer surface and promote ulcer healing.
(3) Antibacterial therapy is a new treatment method because H. pylori may be related to the development of peptic ulcer.
2. Indications for surgical treatment
(1) Massive bleeding that has not been treated with emergency medical treatment.
(2) Acute perforation.
(3) Organic pyloric obstruction.
(4) Gastric ulcer suspected to be cancerous.
(5) Gastric ulcer with no effect by medical treatment.
Precautions
1. Diet. Eat regularly and regularly to maintain the normal rhythm of digestive activity. Avoid stimulating diet or drinks, avoid snacks between meals, do not eat before bedtime, do not eat too much to avoid excessive expansion of the gastric sinus and increase secretion of gastrin, avoid smoking and alcohol. The ulcer should eat less and more meals (5-6 times Md) during the active period, and change to 3 times Md after the symptoms are controlled. 2-3 days before the fecal occult blood test, meat and other blood-containing diets should be abstained.
2. Activity. Live a regular life, pay attention to the combination of work and rest, physical strength and mental strength to regulate each other. Absolute bed rest is required during the active phase of the disease or when there are complications.
3.Review time and indications
(1) Review gastroscopy after one month of regular treatment.
(2) Gastroscopy must be reviewed once a year for those who have discontinued medication, and every six months for patients with gastric ulcer aged over 40 years.
(3) Vomiting blood, blood in the stool, sudden epigastric pain during drug discontinuation or medication must be promptly returned to the hospital.
A few special points to note
1, excessive tension, anxiety, frustration and other mental stress, but the brain higher nerve dysfunction and aggravate the disease, should be avoided as far as possible.
2, avoid the use of drugs that have a large stimulus to the gastric mucosa, such as salicylates, pau d’arco, etc.
3, adhere to the drug maintenance treatment, when using drugs, pay attention to.
(1) acid suppressants should be taken between half an hour and many hours after meals, duodenal ulcers secrete more acid in the evening, reaching a peak at midnight, it is advisable to take an additional dose before bedtime. Aluminum hydroxide gel can cause constipation, so it should be used in combination with milk of magnesia.
(2) Anticholinergic drugs have reactions such as dry mouth, blurred vision, tachycardia, sweat closure, urinary retention, etc., should be explained to the patient, and the dosage can be reduced appropriately. It is prohibited for those who have glaucoma and prostate hypertrophy.
(3) H2 receptor antagonists should be taken before or with meals, and an additional dose at bedtime if needed according to medical advice, and pay attention to any dizziness, drowsiness, rash and other side effects.
4. Closely observe changes in the condition, pay attention to the nature and location of pain and be alert to the following complications.
(1) In case of gastrointestinal hemorrhage, patients may have vomiting blood, blood in stool, accompanied by dizziness, rapid heart rate, pallor, cold sweat and other shock symptoms, which should be dealt with urgently.
(2) In the case of gastric and duodenal perforation, the patient suddenly experiences epigastric pain, abdominal muscle tension, shock and other symptoms, so he/she should fast immediately and be treated accordingly.
(3) In the case of pyloric obstruction, the patient has typical pain rhythmical disappearance, postprandial abdominal pain, and severe vomiting, vomiting acid-containing fermented persistent food, and the above symptoms are relieved after vomiting. In severe cases, imbalance of water and electrolyte balance etc. may occur. It should be treated with fasting, gastric lavage and intravenous fluids.
(4) Cancer. Patients above middle age, with persistent symptoms, often manifesting as persistent pain, loss of rhythm, anorexia, emaciation, lack of gastric acid, positive fecal occult blood, etc.