stomach health

Peptic ulcer

Peptic ulcer is a disease of considerable social relevance. From the data currently available, it appears that in Western countries 2% of the population has an active ulcer, while 6-15% have presented, over the course of life, clinical manifestations compatible with the presence of gastric or duodenal ulcer. Men are affected more frequently than women, with a ratio of 3: 1. The duodenal localization is the most frequent, except in Japanese statistics, in which gastric ulcer prevails. 5-15% of patients have both gastric and duodenal ulcers. In men, the appearance of peptic ulcer is rare before the age of 20, but its incidence increases over the following decades until it reaches a maximum peak at the age of 50. The onset of ulcers in women is infrequent in pre-menopausal age; this suggests a possible protective role played by hormones. The incidence of peptic ulcer, particularly of the duodenal ulcer, has been decreasing in the last 30 years, probably in relation to the discovery of the factors that cause it and to their relative elimination.

Peptic ulcer is a localized lesion that affects the mucosa of the digestive tract exposed to the action of the secreted acid of the stomach. The most frequent location of the ulcer is at the gastric and duodenal level, but it can also appear in the esophagus, in cases of acid or alkaline reflux from the stomach to the esophagus itself, in the jejunum, after a surgery that has removed the lower half of the stomach and the duodenum, in the Zollinger-Ellison syndrome (a often familiar tumor of the endocrine system, and sometimes also in the diverticulum of Mekel (a diverticulum of the small intestine), due to the presence of gastric mucosa when, normally, this should not be.

Gastric secretion of hydrochloric acid and pepsin plays a fundamental role in the onset of the ulcer; in fact it has been shown that peptic ulcer does not occur in the case of achlorhydria (lack of acid secretion). The gastric and duodenal mucous membranes, under normal conditions, are very resistant to the action of the acid-peptic secretion; the onset of the ulcer in the stomach and duodenum is therefore considered the result of an imbalance between the aggressive factors for the mucosa (acid and pepsin, gastrolesive substances, bacteria, etc.) and the defensive factors (mucus and bicarbonate secretion, blood flow of the mucosa, cell renewal), which participate in the formation of the so-called "mucous barrier". The mucosa of the other tracts of the digestive tract is instead particularly sensitive to gastric secretions; acid reflux in the lower portion of the esophagus in subjects with incontinence of the cardia (the valve that separates the esophagus from the stomach), or the passage of chyme acid in the jejunum following surgical removal of a portion of the stomach and duodenum, may in fact induce the onset of peptic ulcers. However, these last two forms have a very low incidence, therefore, with the term of peptic ulcer, the gastro-duodenal ulcerative pathology is commonly indicated, which represents 98% of the entire ulcerative pathology.

If we observe a small portion of tissue that constitutes peptic ulcer under the optical microscope, we can appreciate a lesion of the mucosa and submucosa, almost always solitary, which can be deepened in the gastric or duodenal wall beyond the muscularis mucosae, reaching and often exceeding the muscle frock. This distinguishes ulcers with simple mucosal erosions, characterized by rapid and complete resolution, because they are limited to the epithelium of the mucosa. In some cases, however, mucosal erosion, more than a distinct entity, represents a simple initial stage of the appearance of the ulcer. Gastric and duodenal ulcers are in many respects different from one another; they are therefore illustrated separately.

Laboratory and instrumental surveys

The use of laboratory tests and instrumental investigations is essential to ascertain the diagnosis, formulate the prognosis and guide the therapeutic conduct of diseases of the stomach and duodenum. The most important methods for the study of gastro-duodenal diseases are:

  • digestive endoscopy, with the methods associated with it (endoscopic biopsy, chromoendoscopy, operative endoscopy, endoscopic ultrasound). it is certainly the most frequently used exam, due to the fact that it requires short execution times and uses a simple technique. Moreover, in emergency conditions it can also be performed in the operating room.
  • radiological examination of the first section of the digestive tract with an opaque radio meal;
  • evaluation of gastric secretory activity ;
  • the dosage of gastrinemia .

The search for occult blood in the faeces is a non-specific examination but useful in the initial "diagnostic" phase (screening); the positivity of the test is indicative of a small but constant blood bleeding (oozing) in the digestive tract. The stomach and duodenum are among the most frequent sites of bleeding.

The ultrasound and CT scan of the abdomen are almost always to be considered as second-choice tests, useful for defining the nature of new formations that determine compression from the outside on the stomach and duodenum and to assess the possible involvement of other abdominal organs from part of a primitive gastro-duodenal pathology, such as the frequent liver metastases caused by a gastric tumor.

Selective arteriography of the celiac trunk and superior mesenteric artery can sometimes be used to identify the site of bleeding in the case of ongoing digestive hemorrhage; is a rarely used radiological examination, which has been replaced in most cases by endoscopy.