In the digestive system, the layer that covers the inner surface of the esophagus, stomach and duodenum and is called the mucous membrane, stomach acid, digestive enzymes (pepsin, bile salts and pancreatic enzymes) or drugs. Deep wounds that occur as a result of damage (aspirin and antirheumatic drugs) are called ulcers or peptic ulcers. Stomach acid and pepsin (the enzyme that digests proteins in the stomach) are secretions that are extremely necessary for the digestion of food.
Although stomach acid is a strong acid (pH 1-2), it normally does not cause any damage to the stomach and duodenum. There is a thick mucus layer on the mucosal surface that prevents stomach acid from reaching the mucosa (mucus= slimy substance). In the gastric mucosa, there is a balance between the factors that can damage the mucosa, such as acid, pepsin and bile acids, and the factors that protect the mucosa. The change of this balance in favor of aggressive factors leads to deterioration of mucosal integrity and ulcer formation. Although it is known as stomach ulcer among the people, most of peptic ulcers are found in the duodenum.
Ulcers in the stomach are called gastric ulcers, ulcers in the duodenum are called duoedenal ulcers or bulbar ulcers. They can be from 3-5mm to 5cm wide.
It is thought that approximately 10% of the population has peptic ulcer disease at some point in their lives. It occurs twice as often in men than in women. While duodenal ulcers are common between the ages of 30-45, gastric ulcers occur at older ages (50-65).
WHY DOES ULCERS OCCUR?
Although gastric acid is a potent aggressive factor, it seems impossible by itself to form ulcers. Because gastric acid secretion is increased in only ¼ of ulcer patients and it is within normal limits in half. Although ulcer formation is almost always in question in some diseases in which gastric acid secretion increases excessively, such conditions are very rare (such as Zollinger Ellison syndrome). However, the statement that there can be no ulcer without acid (No acid No ulcer) is still valid today, because it is not possible to heal gastric or duodenal ulcers without suppressing gastric acid secretion. Today, it is accepted that there are two main causes of ulcers. Many patients with gastric and duodenal ulcers are infected (75%) with a bacterium called Helicobacter pylori (HP).
Another group of patients also uses long-term aspirin or non-steroidal antirheumatic drugs (NSAIDs). It is known that 15 million people in the world use NSAIDs, 60% of them describe stomach complaints, 10% of them develop stomach and/or duodenal ulcers, and an average of 3-4% of them have serious complications that require hospitalization. On the other hand, the fact that HP infection or antirheumatic drug use cannot be detected in approximately 1/5 of the ulcer patients is an indication that the etiopathogenesis of ulcer is not yet fully understood.
Although the stress factor, which was thought to be an important cause of ulcer formation in previous years, has lost its importance today, serious stomach and/or duodenal ulcers can occur in cases where the body is exposed to extreme stress (for example, extensive body burns, head traumas and staying in intensive care). It is known that patients with ulcers may experience increased stress after exposure to stress.
THINGS TO KNOW ABOUT HELICOBACTERY PYLORI (HP)
HP is a spiral-shaped bacterium that settles in the stomach when taken orally and causes a chronic infection and inflammation (inflammation), which we call gastritis here. It lives under the mucus layer that covers the gastric mucosa, protecting it from stomach acid and other factors. HP makes the gastric mucosa sensitive to acid and other aggressive factors by weakening the mucus layer with both the toxins it secretes and some substances that appear after the body’s immune response against the bacteria (the body’s immune system responds to the bacteria). It has been shown that approximately 80% of our society is infected with this bacterium.
Although HP infection is accepted as one of the leading factors in peptic ulcer formation, the absence of ulcers in all people infected with this bacterium and the detection of HP negative ulcers at an increasing rate in recent years suggest that other factors besides HP are effective in ulcer formation. HP seems to play a more important role in ulcer recurrence than ulcer formation.
Today, diseases that are accepted to be caused by HP infection are seen in the figure. HP has been accepted among the 1st degree carcinogenic factors by the World Health Organization (WHO). The presence of bacteria in the stomach can be demonstrated by tests such as endoscopic biopsy, urea-breath testing, and searching for antibodies and antigens in blood and stool. In patients with peptic ulcer in whom the presence of HP is detected in the stomach, some special drug regimens are used to treat HP, and bacteria are cleared from the stomach. The effectiveness of this treatment is around 80%.
WHAT ARE THE SYMPTOMS OF ULCERS?
The most common manifestation of ulcer is a blunt pain felt in the upper abdomen, between the two rib arcs and between the lower end of the breastbone and the navel, in an area usually expressed with the palm of the hand. The pain may be crushing, scraping or burning, and may radiate to the back between the two shoulder blades and to the sides of the abdomen. It can wake you up at night. Nausea and vomiting may accompany the pain. The pain may last for a period ranging from 15-20 minutes to several hours. It can start after fasting.
It is usually relieved or resolved with food or antacid intake. Therefore, patients may need to eat frequently. In patients with stomach ulcers, the pain may increase after eating, and bloating and gas may be more pronounced. In some patients, bleeding or perforation may be the first sign of an ulcer when there are no symptoms. Weight loss can be seen in patients with a predominant complaint of vomiting. In some patients, the complaints may show seasonal changes and intensify, especially in the spring.
HOW IS ULCERS DIAGNOSED?
The diagnostic method to be applied in patients who apply to a doctor with ulcer-like complaints is endoscopy (Gastroscopy), which allows the diagnosis of the ulcer by direct visualization and tissue sampling when necessary. In rare cases, barium gastric duodenal radiography may be helpful in the diagnosis. In order to exclude the possibility of cancer in patients with suspected gastric ulcer, endoscopic examination should be performed and a tissue sample (biopsy) should be taken for examination.
HOW IS ULCER TREATED?
The first step in ulcer treatment is to reduce stomach acid. When acid secretion is suppressed, pepsin, an enzyme that can become active only in an acid environment, is also inactivated. Today, ulcer treatment can be done quite successfully thanks to drugs that suppress gastric acid secretion strongly. Your doctor will decide how long the active drug treatment will continue. In addition to reducing acid secretion, the second thing to do in ulcer treatment is to treat this bacteria in patients with HP in their stomachs. This treatment is usually done using 1 or 2 week treatment regimens that include at least two types of antibiotics. Your doctor will decide which treatment regimen to choose.
HP treatment is especially important in terms of preventing ulcer recurrence. Treating the bacteria alone is insufficient to treat ulcers, a sufficient period of suppression of gastric acid is required for the ulcer to heal (usually 6-8 weeks). Stomach ulcers usually require longer treatment. Gastric ulcers should be checked endoscopically after treatment and the patient should not be left unfollowed until they are completely healed.
Aspirin and/or antirheumatic drugs should be discontinued in patients with ulcers. These drugs can only be used when necessary under the supervision of a doctor.
It would be appropriate to make some changes in the lifestyles of patients, such as quitting smoking and reducing alcohol consumption, while drug treatment is ongoing. Ulcer recurs more frequently in patients who continue to smoke. Since hot, spicy, acidic and caffeine-containing foods and beverages and alcohol may cause an increase in complaints during the active periods of ulcer, their consumption may be restricted in the early stages of treatment.
Apart from this, a special diet is not required in the ulcer patient. Patients who like to drink milk may be allowed to drink 1-2 glasses of milk a day. It is undesirable to drink milk at frequent intervals for treatment purposes. In patients living a stressful life, approaches to reduce stress can be helpful in treatment. (Emphasis on hobbies, psychotherapy, yoga, etc.)
Today, surgical treatment is only applied when complications such as bleeding, obstruction and perforation occur that do not respond to medical and endoscopic treatment.
WHAT ARE THE COMPLICATIONS OF ULCERS?
Bleeding, obstruction (narrowing of gastric outlet due to ulcer-obstruction) and perforation are the main complications of ulcer.
Bleeding: It is one of the serious complications of ulcer. Nausea, coffee grounds or red bloody vomit, weakness, palpitations, cold sweats, dizziness, darkening of the eyes and soft tarry stools are the signs of ulcer bleeding. The severity of these symptoms is directly proportional to the severity of the bleeding. When the bleeding is heavy, the stool may come in a dark red color. When there is bleeding, pain is usually not felt. Patients who have bleeding should be hospitalized, followed up and treated, and active bleeding, if any, should be stopped by endoscopy. Rarely, surgical treatment may be needed.
Occlusion: In chronic duodenal ulcers, severe narrowing of the gastric outlet may occur due to the deformation and narrowing of the intestine over time. The main complaints in these patients are vomiting of food eaten 10-12 hours ago and bad breath caused by food left in the stomach. Patients state that they vomit the food they ate for dinner the next day when they vomit. Although sometimes a response to medical treatment can be obtained, endoscopic balloon dilation, stenting, or surgical treatment is usually required.
Perforation: It is a rare complication today due to the use of powerful drugs. The most important finding is the sudden onset of severe abdominal pain in the upper part of the abdomen, stabbing, and spreading to the entire abdomen within hours. If left untreated, it causes death due to widespread peritonitis. After the diagnosis is made, the treatment is surgery.
