see peptic ulcer; Zollinger-Ellison syndrome.
Causes It is likely that there is some abrasion, or break, in the lining membrane (or mucosa) of the stomach and/or duodenum, and that it is gradually eroded and deepened by the acidic gastric juice. The bacterium helicobacter pylori is present in the antrum of the stomach of people with peptic ulcers; 15 per cent of people infected with the bacterium develop an ulcer, and the ulcers heal if H. pylori is eradicated. Thus, this organism has an important role in creating ulcers. Mental stress may possibly be a provocative factor. Smoking seems to accentuate, if not cause, duodenal ulcer, and the drinking of alcohol is probably harmful. The apparent association with a given blood group, and the fact that relatives of a patient with a peptic ulcer are unduly likely to develop such an ulcer, suggest that there is some constitutional factor.
Symptoms and signs Peptic ulcers may present in di?erent ways, but chronic, episodic pain lasting several months or years is most common. Occasionally, however, there may be an acute episode of bleeding or perforation, or obstruction of the gastric outlet, with little previous history. Most commonly there is pain of varying intensity in the middle or upper right part of the abdomen. It tends to occur 2–3 hours after a meal, most commonly at night, and is relieved by some food such as a glass of milk; untreated it may last up to an hour. Vomiting is unusual, but there is often tenderness and sti?ness (‘guarding’) of the abdominal muscles. Con?rmation of the diagnosis is made by radiological examination (‘barium meal’), the ulcer appearing as a niche on the ?lm, or by looking at the ulcer directly with an endoscope (see FIBREOPTIC ENDOSCOPY). Chief complications are perforation of the ulcer, leading to the vomiting of blood, or HAEMATEMESIS; or less severe bleeding from the ulcer, the blood passing down the gut, resulting in dark, tarry stools (see MELAENA).
Treatment of a perforation involves initial management of any complications, such as shock, haemorrhage, perforation, or gastric outlet obstruction, usually involving surgery and blood replacement. Medical treatment of a chronic ulcer should include regular meals, and the avoidance of fatty foods, strong tea or co?ee and alcohol. Patients should also stop smoking and try to reduce the stress in their lives. ANTACIDS may provide symptomatic relief. However, the mainstay of treatment involves four- to six-week courses with drugs such as CIMETIDINE and RANITIDINE. These are H2 RECEPTOR ANTAGONISTS which heal peptic ulcers by reducing gastric-acid output. Of those relapsing after stopping this treatment, 60–95 per cent have infection with H. pylori. A combination of BISMUTH chelate, amoxycillin (see PENICILLIN; ANTIBIOTICS) and METRONIDAZOLE – ‘triple regime’ – should eliminate the infection: most physicians advise the triple regime as ?rst-choice treatment because it is more likely to eradicate Helicobacter and this, in turn, enhances healing of the ulcer or prevents recurrence. Surgery may be necessary if medical measures fail, but its use is much rarer than before e?ective medical treatments were developed.... duodenal ulcer
Symptoms The onset may be sudden or insidious. In the acute form there is severe diarrhoea and the patient may pass up to 20 stools a day. The stools, which may be small in quantity, are ?uid and contain blood, pus and mucus. There is always fever, which runs an irregular course. In other cases the patient ?rst notices some irregularity of the movement of the bowels, with the passage of blood. This becomes gradually more marked. There may be pain but usually a varying amount of abdominal discomfort. The constant diarrhoea leads to emaciation, weakness and ANAEMIA. As a rule the acute phase passes into a chronic stage. The chronic form is liable to run a prolonged course, and most patients suffer relapses for many years. SIGMOIDOSCOPY, BIOPSY and abdominal X-RAYS are essential diagnostic procedures.
Treatment Many patients may be undernourished and need expert dietary assessment and appropriate calorie, protein, vitamin and mineral supplements. This is particularly important in children with the disorder. While speci?c nutritional treatment can initiate improvement in CROHN’S DISEASE, this is not the case with ulcerative colitis. CORTICOSTEROIDS, given by mouth or ENEMA, help to control the diarrhoea. Intravenous nutrition may be required. The anaemia is treated with iron supplements, and with blood infusions if necessary. Blood cultures should be taken, repeatedly if the fever persists. If SEPTICAEMIA is suspected, broad-spectrum antibiotics should be given. Surgery to remove part of the affected colon may be necessary and an ILEOSTOMY is sometimes required. After recovery, the patient should remain on a low-residue diet, with regular follow-up by the physician, Mesalazine and SULFASALAZINE are helpful in the prevention of recurrences.
Patients and their relatives can obtain help and advice from the National Association for Colitis and Crohn’s Disease.... ulcerative colitis
The drugs used in combination are:
The receptor antagonists, which reduce the output of gastric acid by histamine H2receptor blockade; they include CIMETIDINE, FAMOTIDINE and RANITIDINE.
ANTIBIOTICS to eradicate Helicobacter pylori infection, a major cause of peptic ulceration. They are usually used in combination with one of the PROTON-PUMP INHIBITORS and include clarithomycin, amoxacillin and metronidazole.
BISMUTH chelates.
The prostaglandin analogue misoprostol has antisecretory and protective properties.
Proton-pump inhibitors omeprazole, lansoprazole, pantaprazole and rabeprazole, all of which inhibit gastric-acid secretion by blocking the proton pump enzyme system.... ulcer healing drugs
It is especially useful in the diagnosis of Crohn’s disease, coeliac disease, lymphoma, and other causes of malabsorption.
The biopsy is taken using an endoscope passed down the throat into the small intestine, via the stomach.... jejunal biopsy
The most common cause is a sexually transmitted infection, particularly syphilis and genital herpes (see herpes, genital).
Chancroid and granuloma inguinale are tropical bacterial infections that cause genital ulcers.
Lymphogranuloma venereum is a viral infection producing genital blisters.
Behçet’s syndrome is a rare condition that causes tender, recurrent ulcers in the mouth and on the genitals.
Cancer of the penis or vulva may first appear as a painless ulcer with raised edges.... genital ulcer
There are various types of ulcer.
Venous ulcers (also referred to as varicose or stasis ulcers) occur mainly on the ankles and lower legs and are caused by valve failure in veins; they usually appear in conjunction with varicose veins.
Bedsores (decubitus ulcers) develop on pressure spots on the legs due to a combination of poor circulation, pressure, and immobility over a long period.
Leg ulcers can also be due to peripheral vascular disease and diabetes mellitus.
In the tropics, some infections can cause tropical ulcers.... leg ulcer
The gums become sore and bleed at the slightest pressure. Crater-like ulcers develop on the gum tips between teeth, and there may be a foul taste in the mouth, bad breath, and swollen lymph nodes. Sometimes, the infection spreads to the lips and cheek lining (see noma).
A hydrogen peroxide mouthwash can relieve the inflammation.
Scaling is then performed to remove plaque.
In severe cases, the antibacterial drug metronidazole may be given to control infection.... gingivitis, acute ulcerative
Stress ulcers are usually multiple and are most common in the stomach.
The exact cause is unknown.
Drugs are often given to severely ill patients in hospital to prevent the development of stress ulcers.... stress ulcer
Each ulcer is usually small and oval, with a grey centre and a surrounding red, inflamed halo. The ulcer, which usually lasts for 1–2 weeks, may be a hypersensitive reaction to haemolytic streptococcus bacteria. Other factors commonly associated with the occurrence of these ulcers are minor injuries(such as at an injection site or from a toothbrush), acute stress, or allergies (such as allergic rhinitis). In women, aphthous ulcers are most common during the premenstrual period. They may also be more likely if other family members suffer from recurrent ulceration.
Analgesic mouth gels or mouthwashes may ease the pain of an aphthous ulcer.
Some ointments form a waterproof covering that protects the ulcer while it is healing.
Ulcers heal by themselves, but a doctor may prescribe a paste containing a corticosteroid drug or a mouthwash containing an antibiotic drug to speed up the healing process.... ulcer, aphthous
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