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  • Julio Alejandro Murra Saca, MD
    Gastroenterologist

  • Tel: (503) 2226-3131, 2225-3087, 2530-3334 al 37
    Edificio Centro Scan, Colonia Médica

  • San Salvador, El Salvador

GASTRIC ULCERS AND THE DUODENUS

Gastric ulcers and duodenal are relatively frequent clinical entities
At the moment the most exactly method to detected the ulcers is videoendoscopy of the upper digestive tract. The doctor eases a gastroscope, a thin tube containing a tiny camera, through your mouth and down into your stomach to look at the stomach lining.
The symptoms can be diverse but they can vary from patient to patient which can be that an ulcer evolves without causing pain, until extremely severe pain which can interrupt the patient´s dream. Differential diagnosis are of other diseases into abdominal wall, gastric level, gallbladder, pancreas etc. It is important to emphasize that there are some people confused with this disease since, somebody or doctor said to them that they even had ulcer without endoscopy and they think that all the life will have the ulcer but nevertheless it is necessary to emphasize that the ulcers are completely curable with the modern treatment that the doctors used. The ulcers as much gastric as duodenal are cured but taking in a month with suitable processings. The danger of an ulcer is the complications that can cause which can put in danger the life of a patient as they are bleeding, perforation. If after a month with the processing, the symptoms persist it can be that the ulcer is hiding a gastric cancer. See photos and videos of some ulcers detected by videoendoscopy in our clinic. 

ENDOSCOPY Endoscopy provides a sensitive, specific, and safe method for diagnosing peptic ulcers, allowing direct inspection and biopsy. Determining the sensitivity of endoscopy depends upon the gold standard used for comparison
HELICOBACTER PYLORI There is a strong relationship between H. pylori infection and the development of peptic ulcer disease. Peptic ulcer changed dramatically in the 1980s with reports of a causal association between Helicobacter pylori infection and ulcer disease, particularly duodenal ulcer. Although this concept met with a great deal of initial skepticism, the association is now universally accepted. It is now the accepted standard of care to test for H pylori infection in all patients with either an active ulcer or just as important a past history of ulcer disease. However, this is far from being the "end of the story" for ulcer disease. For many patients, it is appropriate to consider ulcer disease as a treatable (and curable) complication of a chronic bacterial infection

There are four major complications of peptic ulcer:

Bleeding: Upper gastrointestinal (UGI) bleeding secondary to peptic ulcer is a common medical condition that results in high patient morbidity UGI bleeding commonly presents with hematemesis (vomiting of blood or coffee-ground like material) and/or melena (black, tarry stools). Hematochezia, usually a sign of a lower GI source, can also be seen with massive UGI bleeding. A nasogastric tube lavage which yields blood or coffee-ground like material confirms this clinical diagnosis; however, lavage may be negative if bleeding has ceased or arises beyond a closed pylorus.Most patients with bleeding ulcers can be managed with fluid and blood resuscitation, medical therapy, and endoscopic intervention, as appropriate. The mortality from peptic ulcer bleeding has not changed materially in recent years and remains at 7% to 10% despite advances in patient management. Those found to have bled from an ulcer should receive endoscopic hemostatic therapy (eg, with injection sclerotherapy and/or the application of a thermal coagulation device such as the heater probe) if there is active bleeding, a non bleeding visible clot, or possibly an adherent clot in the ulcer base (although the last remains somewhat controversial).
Perforation: Duodenal, antral, and gastric body ulcers account for 60, 20 and 20 percent of perforations due to peptic ulcer, respectively . One-third to one-half of perforated ulcers are associated with NSAID use; these usually occur in elderly patients 
Penetration:
Ulcer penetration refers to penetration of the ulcer through the bowel wall without free perforation and leakage of luminal contents into the peritoneal cavity. Surgical series suggest that penetration occurs in 20 percent of ulcers, but only a small proportion of penetrating ulcers become clinically evident .Penetration occurs in descending order of frequency into the pancreas, gastrohepatic omentum, biliary tract, liver, greater omentum, mesocolon, colon, and vascular structures. Antral and duodenal ulcers can penetrate into the pancreas. Penetration can also involve pyloric or pre pyloric ulcers penetrating the duodenum, eventually leading to a gastroduodenal fistula evident as a "double" pylorus. A long-standing ulcer history is common but not invariable in patients who develop penetration Penetration often comes to attention because of a change in symptoms or involvement of adjacent structures. The change in symptom pattern may be gradual or sudden; it usually involves a loss of cyclicity of the pain with meals, and loss of food and antacid relief. The pain typically becomes more intense, of longer duration, and is frequently referred to the lower thoracic or upper lumbar region.The diagnosis of penetrating ulcer is suspected clinically when an ulcer in the proper region is found. Mild hyperamylasemia can develop with posterior penetration of either gastric or duodenal ulcer, but clinical pancreatitis is uncommon .Penetration can be associated with a wide array of uncommon complications including perivisceral abscess (evident on CT or ultrasonography)], erosion into vascular structures leading to exsanguinating hemorrhage (aortoenteric fistula) , or erosion into the cystic artery . Rare biliary tract complications include erosion into the biliary tree with choledochoduodenal fistula, extra hepatic obstruction, or hematobilia. Fistulization into the pancreatic duct has also been reported with penetrating duodenal ulcer fistulae are seen with greater curvature gastric ulcers, particularly marginal ulcers . Typical features of this complication include pain, weight loss, and diarrhea; feculent vomiting is an uncommon, but diagnostic symptom. A duodenocolic fistula can also occur .No rigorous studies are available to guide the management of penetrating ulcers. One can assume that management should follow the intensive measures outlined for refractory ulcers.


Obstruction:Gastric outlet obstruction is the least frequent ulcer complication. Most cases are associated with duodenal or pyloric channel ulceration, with gastric ulceration accounting for only 5 percent of cases. 

NSAID's and Ulcer Disease. Nonsteroidal anti-inflammatory drugs 
Apart from H pylori infection, NSAID (or aspirin) use is the other major identifiable risk factor for PUD. Accounts for the majority of H pylori–negative ulcers.


Gastric Ulcers Overture


Endoscopy of Giant Ulcer of the Stomach


This diagram shows the detection of ulcers by endoscopy.


Hemorrhage due to Duodenal Ulcer


Giant Duodenal Ulcer