UNEXPLAINED WEIGHT LOSS | ||||
While weight loss itself is not a specific | ||||
symptom of peptic ulcer disease, its | ||||
presence can indicate severe disease, | ||||
complications or potential gastric | ||||
malignancy. In the setting of peptic | ||||
ulcer disease, weight loss may be the result of reduced appetite, malabsorption | ||||
, increased metabolic demand or | ||||
underlying malignancy. | ||||
|
Helicobacter pylori and malignancy
H. pylori thrives in the acidic environment
| ||||
of the stomach; the inflamma- |
Figure 4. Duodenal ulcer. |
tory response that is generated can lead to mucosal injury and epithelial cell degeneration. This chronic inflammation |
|||
leads to the development of |
Professor Yutaka Tsutsumi, Fujita Health University School of Medicine / bit. ly / 3EX9ZAe |
ulcers and also predisposes to a significant risk of malignancy, particularly gastric carcinoma. This is because the environment is conducive to genetic mutations and cellular changes.
Several mechanisms contribute to this link between H. pylori infection, peptic ulcer disease and malignancy. Chronic ulcer inflammation leads to oxidative stress and DNA damage to the cells, promoting malignant transformation. Chronic H. pylori infection may result in hypochlorhydria or hyperchlorhydria, depending on the distribution of gastritis.
Depending on the location of gastritis, a patient may either develop an increased risk of ulceration or malignancy. 30
Combined with the ability of H.
|
|||
pylori to disrupt key cellular pathways | ||||
involved with cell growth, | ||||
repair and apoptosis, these factors all | ||||
contribute to the risk of progression | ||||
from premalignant cellular changes | ||||
to malignancy. |
Figure 5. Electron micrograph of Helicobacter pylori demonstrating multiple flagella( negative staining). |
INVESTIGATIONS
GASTROSCOPY is the gold standard investigation for evaluation. However, peptic ulcer disease can pose diagnostic challenges because of the variability of its presentation and potential complications. A judicious selection of
|
|||
investigations is, therefore, pivotal to |
||||
intensity, be intermittent in nature |
burning sensation radiating from |
prevention of further complications. |
( melaena). In severe cases, patients |
guide effective management. |
and radiate to the back. The relationship between meals and symptoms is centred around the dynamic inter- |
the xiphoid process to the neck, and regurgitation, are symptoms more typically associated with gastro- |
In addition to patients reporting a positive family history of upper gastrointestinal malignancy, other red flag |
with massive gastrointestinal bleeding may describe the passage of fresh, red blood( haematochezia), which can be a |
Laboratory tests
Blood tests are not specific for the
|
play between gastric acid secretion, |
oesophageal reflux disease( GORD) |
symptoms may include gastrointes- |
result of a rapid transit of blood through |
diagnosis but may indicate compli- |
mucosal protection and the buffering |
rather than peptic ulcer disease. |
tinal bleeding, severe and persistent |
the gastrointestinal tract. |
cations that arise as a result of pep- |
effect of ingested food. |
Note that while patients with peptic |
abdominal pain, iron deficiency anae- |
tic ulcer disease. Perform an FBC and |
|
Classically, patients with duodenal |
ulcer disease commonly also have |
mia and unexplained weight loss. 24 |
SEVERE AND PERSISTENT |
EUC; this may identify anaemia and |
ulcers may report worsening abdom- |
GORD, these conditions have differ- |
ABDOMINAL PAIN |
determine if there is a rise in urea |
|
inal pain while the stomach is empty, |
ing underlying mechanisms for their |
GASTROINTESTINAL BLEEDING |
Intense and / or persistent abdominal |
in the context of bleeding from the |
2-3 hours after a meal or at night. Sev- |
clinical presentations and, may thus |
Gastrointestinal bleeding( melaena / |
pain may be due to complications of |
upper gastrointestinal tract. The pres- |
eral mechanisms contribute to the |
present with different symptoms. 23 |
haematemesis / haematochezia) is a |
ulcer penetration, or as a result of a |
ence of iron deficiency may support |
|
emergence of these nocturnal symptoms, including elevated production of gastric acid at night( as gastric acid secretion follows a circadian rhythm) and the absence of a food buffer.
Conversely, patients with pep-
|
Symptoms associated with peptic ulcer complications
If peptic ulcer disease is suspected,
evaluate patients further for the presence of red flag symptoms,
|
common complication of peptic ulcer disease, occurring in up to 15-20 % of patients. 25 This complication occurs when an ulcer erodes into blood vessels, causing bleeding into the gastrointestinal tract( see figure 6). |
gastric or duodenal perforation, which may occur in up to 10 % of peptic ulcers. 26 The onset of these symptoms may be gradual or sudden. Clinical examination may reveal a rigid abdomen with rebound tenderness |
chronic gastrointestinal bleeding as a cause of anaemia.
Testing for Helicobacter pylori
All patients with peptic ulcer dis-
|
tic ulcers may report food-provoked |
which may suggest complications. |
Patients may present with nau- |
( peritonitis), fever, haemodynamic |
ease require testing for H. pylori. The |
symptoms of nausea, vomiting, post- |
The identification of these red flag |
sea, vomiting of bright red or coffee |
instability or shock. As peptic ulcers |
non-invasive urea breath test and |
prandial fullness and bloating. 23 Heartburn, often described as a |
symptoms is crucial for a timely diagnosis, appropriate management and |
ground-like material( haematemesis) and passing dark or black, tarry stools |
may also penetrate into surrounding organs including the liver, pancreas, |
stool antigen test are both more accurate than serology. 31 However, the |