There are two main sites of peptic ulcer- Gastric and duodenal.
Rare peptic ulcers may be seen in the:
- Cardiac end of the esophagus.
- Meckel’s diverticulum.
- In any segment of bowel which has been surgically anastomed to the gastric fundus.
Peptic ulcers may be acute ulcers, which are shallow and multiple and chronic ulcers, which are single, deep and scirrhous.
Acute Peptic Ulcers
- Half of the patients give history of ingestion of aspirin or anti-inflammatory drugs.
- Sometimes these acute ulcers may occur following stress, when they are called ‘stress ulcers’. This may occur following hypotension from hemorrhage, endotoxin shock or cardiac infarction.
- Sepsis is an important etiological factor.
- Acute ulcers are seen after cerebral trauma or neurological operations.
- After major burns acute ulcers may be seen (Curling’s ulcer).
- Patients on steroids may develop acute ulcers, known as ‘steroid ulcers’.
Chronic Peptic Ulcers
- Gastric ulcer patients secrete either low normal or below normal amounts of acid. Only 5% of patients may demonstrate acid hyper-secretion.
- Diminished mucosal resistance due to lowering of the ability to resist the effect of acid pepsin digestion causes gastric ulcer.
- Regurgitated bile and other duodenal juices have been taken to be the prime cause of pre-ulcerative superficial gastritis.
- A surface layer of mucus protects normally from the digestive effect of the hydrochloric acid and pepsin. When this mucous barrier becomes deficient gastric ulcer may develop.
- 85% of gastric ulcers occur along the lesser curve of the stomach.
- As the gastric ulcer patients have low acid content, some factors such as injury to the gastric mucosa which renders it more susceptible to acid peptic damage may lead to ulcer formation.
- Non-steroidal anti-inflammatory drugs in patients suffering from arthritis on a long term basis are a significant etiological factor in present times.
- Helicobacter pylori-which exits in the deep mucosal layer of the antrum mainly and duodenum, is rarely associated with ulcer disease.
- Duodenal ulcer is seemingly simplified at first sight by a clear relationship to over-production of hydrochloric acid by the stomach.
- Diminished power of resistance of the mucosa has also been incriminated to cause duodenal ulcer. This can be genetic in origin.
- There are various endocrine dysfunctions (Cushing’s syndrome, Zollinger-Ellison syndrome, parathyroid tumor) that can cause duodenal ulcer.
- Ulceration of both stomach and duodenum has co-existed with disease of the liver particularly cirrhosis.
- Anxiety, stress and strain have always been incriminated to cause peptic ulcer.
- Irregular diet, spicy food and excessive drinking tea and coffee have always provoked ulcer formation.
- Smoking does appear to predispose ulcer formation.
- Helicobacter pylori have been isolated in 100% of duodenal ulcer cases.