Stomach ulcer – Causes, Pathogenesis, symptoms, and treatment

Stomach ulcer is a chronic recurrent disease in which defects occur in the lining of the stomach. In the absence or untimely treatment, it can cause disability or death.

People aged 20 to 65 suffer from gastric and duodenal ulcers. Men from 25 to 40 years old get sick 5-6 times more often than women for the reason that male sex hormones indirectly increase the acidity and aggressiveness of gastric juice, and female – lower it.

According to the World Health Organization, peptic ulcer disease affects from 5 to 10% of the world’s population, and the number of patients with a complicated ulcer has increased several times over the past decade.

In the world, about 330,000 operations for stomach ulcers are performed annually, of which only in Russia – 50,000. In the vast majority, these complex and severe surgical interventions are performed in case of emergency treatment of patients in a weakened state with an already advanced complicated form of the disease. Therefore, even with the most modern medical technologies, postoperative mortality among these patients ranges from 3-5% [10] . And people who have successfully undergone surgical treatment have a high level of disability, which makes it difficult or impossible for patients to return to a normal quality life [6] .

The most common cause of gastric and duodenal ulcers is Helicobacter Pylori infection . It is detected in approximately 70% of patients with stomach ulcers and up to 90% of patients with duodenal ulcers [15] . The prevalence of H. pylori, as the main cause of the development of gastric and duodenal ulcers, has decreased in recent years in developed countries (for example, in Sweden it is 11%). As a rule, this is associated with an improvement in the quality of medical care, which allows timely diagnosis and treatment of an infection, as well as an improvement in sanitary conditions (for example, the quality of tap water). In Russia, the prevalence of infection reaches about 70%, while the majority of infected people do not even know about it and do not complain about anything. [1] .

Helicobacter Pylori

The second most important cause of peptic ulcer disease is anesthetic drugs , in particular non-steroidal anti-inflammatory drugs (NSAIDs) [15] . On the one hand, the speed and universality of the action of NSAIDs relieved people of various pains, on the other hand, because of the long-term uncontrolled intake of these drugs, “medicinal” ulcers of the stomach and duodenum began to appear more often.

In third place among the causes of stomach and duodenal ulcers are diseases that increase the production of gastrin – a hormone that increases the production of hydrochloric acid and increases the aggressiveness of gastric juice. These include B12-deficiency anemia, gastrinoma (pancreatic tumor) [14] , etc.

The likelihood of developing peptic ulcer disease is greatly influenced by predisposing factors , which are:

  • smoking [14] ; 
  • neuro-emotional stress (stress);
  • violation of the daily regimen and nutrition, the use of refined products and fast food;
  • burdened heredity (for example, the presence of peptic ulcer disease in parents) [8] [9] .
If you find similar symptoms, consult your doctor. Do not self-medicate – it is dangerous to your health!

Stomach ulcer symptoms

Pain is the most common symptom of stomach ulcers. It is localized in the upper abdomen, may decrease or increase immediately or after a time after eating, depending on the location of the ulcer. And with the localization of an ulcer in the duodenum, the pain may increase (or decrease) 30-40 minutes after eating.

The intensity of pain varies from severe and transient , which can even lead to reflex vomiting immediately after eating, to weak and constant , which intensifies in the morning and disappears after eating [14] . Sometimes the patient may wake up at night due to the feeling of “sucking in the spoon” (in the area of ​​the hollow under the ribs) or pain in the upper abdomen [2] .

Stomachache

The feeling of “early satiety” and heaviness in the stomach are also signs of peptic ulcer disease. A person often begins to reduce portions of food, since the absorption of even a small amount of food that gets on the inflamed areas of the gastric mucosa and ulcers can cause these unpleasant sensations.

Bad breath, nausea, change in taste sensations, plaque on the tongue are frequent companions of any inflammatory diseases of the upper gastrointestinal tract, including gastritis (inflammation of the stomach), against which ulcers most often appear.

Plaque on the tongue with stomach ulcers

The painless form of peptic ulcer disease is most dangerous for its formidable complications, which sometimes develop with lightning speed in a seemingly healthy person. Sometimes they lead to fatal consequences. For example, at the time of perforation of an ulcer of the stomach wall through and through, a patient develops a pronounced intense pain, which leads to a shock disorienting state, sometimes with loss of consciousness. It is scary to imagine what it will lead to if this person turns out to be the driver of a car, a bus or an airplane pilot. The same trouble can overtake a person who is resting far from civilization: due to the lack of the opportunity to receive emergency medical care, the chances of survival are significantly reduced [5] [7] .

Pathogenesis of stomach ulcers

A stomach ulcer is formed when the balance between the aggressive factors of gastric juice – hydrochloric acid and enzymes – and the protective properties of the mucous membrane – the renewal of the epithelium (the surface of the gastric mucosa), the production of mucus, adequate blood supply, and the production of prostaglandin hormones – are disturbed.

The role of aggressiveness of gastric juice in the formation of ulcers depends on gastric secretion, which, according to IP Pavlov [12], goes through three phases:

  • The first phase – reflex – is caused by irritation of the branches of the vagus nerve, activates the gastric glands, which produce gastric juice. This occurs reflexively in response to the smell or type of food, when it enters the stomach.
  • The second phase – hormonal – depends on the entry into the blood of the hormone gastrin, which is produced by the mucous membrane of the antral (outlet) part of the stomach and the initial part of the duodenum when they are irritated by food masses or inflammatory processes.
  • The third phase – intestinal – depends on the entry into the blood of the hormone enterokinase. This hormone is produced in the small intestine when a lump of food enters it.

In an adult, one and a half liters of gastric juice is secreted per day, while 80% of the juice is produced in the first phase of gastric secretion, 15% in the second and 5% in the third. If violated, these phases can change significantly. For example, in case of inflammation in the antrum of the stomach, too much of the hormone gastrin is secreted, which is why gastric juice is produced in excess “at idle”. This increases inflammation and leads to the appearance of ulcerative defects in the wall of the stomach or duodenum [3] [8] .

An important role in ulceration is played by H. pylori infection , which acts in two ways: on the one hand, bacteria attach to cells, produce toxins and cause inflammation, which makes the mucous membrane more sensitive to aggressive factors; on the other hand, they produce certain substances, due to which the cells of the stomach produce excess hydrochloric acid.

Toxins secreted by H. pylori

With prolonged uncontrolled intake of non-steroidal anti-inflammatory drugs (NSAIDs), the protection of the gastric mucosa is impaired. At the same time, the aggressiveness of the gastric juice increases, due to which the cells of the mucous membrane are damaged and die, after which an ulcer gradually forms.

Chronic overwork and prolonged stress weaken the general immunity and cellular defense, and through the neurohumoral mechanism increase the acidity of gastric juice. This upsets the balance between the factors of aggression and defense, which leads to the appearance of “stress” ulcers, which were first described back in 1983 by Dr. J. Svan [11] .

A number of diseases are accompanied by persistently increased hyperproduction of hydrochloric acid, due to which the compensating capacities of the stomach tissues are depleted and multiple ulcers appear.

A separate role is assigned to predisposing factors. For example, the action of nicotine when using tobacco leads to a spasm of the vessels of the whole organism, including the vessels of the stomach wall and duodenum, disrupting blood circulation in them. Because of this, the mucous membrane experiences oxygen starvation, metabolic processes in it deteriorate, which leads to a weakening of tissue protection and creates the prerequisites for ulceration.

Stages of ulcer formation

A stomach ulcer is extremely rare in an absolutely healthy person. Its appearance is preceded by a number of pathological changes.

At first, due to the disturbed balance between the factors of aggression and protection, a banal chronic inflammation of the stomach appears – chronic gastritis . This condition can last for years, and its manifestations range from the absence of any complaints to the onset of pain in the upper abdomen and indigestion. Chronic gastritis occurs with periods of exacerbation, more often in spring and autumn.

Without treatment, against the background of all the same negative factors, increased aggressiveness of gastric juice and depletion of the protective properties of the mucous membrane, its cells begin to actively die, which leads to the appearance of surface defects – erosion. The body fights these processes, filling the eroded areas with fibrin – a kind of “foam”. But when this resource is depleted, aggressive gastric juice begins to infect the deep layers of the stomach and duodenum that remain unprotected, thus forming an ulcer defect.

The gradual deepening and expansion of the ulcer can lead to damage to the muscles of the gastric wall and erosion of the walls of large vessels, which causes gastrointestinal bleeding. Alternatively, the ulcer may “grow” into the gastric wall through and through, which will lead to the outpouring of stomach contents into the abdominal cavity.

Classification and stages of development of stomach ulcers

Peptic ulcer and duodenal ulcer is a versatile disease in its manifestations and course, which is classified according to various factors.

Due to the appearance, they are more common:

  • ulcers associated with H. pylori infection;
  • “medicinal” ulcers – associated with medication (NSAIDs);
  • “stress” ulcers – caused by physical or psychological overwork of a person or arising after surgery.

By the nature of the flow, there are:

  • newly diagnosed peptic ulcer (acute ulcer);
  • recurrent course (chronic ulcer) with rare exacerbations – every 2-3 years;
  • recurrent course with frequent exacerbations – twice a year or more.

According to the clinical course, the ulcer is typical and atypical.

According to the acid-producing function , an ulcer is isolated with increased, normal or low acidity.

According to the localization of the ulcer defect, a stomach ulcer, a duodenal ulcer or a combined form of the disease are isolated.

By the number of defects, there is a single ulcer and multiple ulcers.

Single and multiple stomach ulcers

According to the maximum size of the defect, ulcers are divided into:

  • small – up to 5 mm;
  • medium – 5-10 mm;
  • large – for the stomach – 11-29 mm; for the duodenum – 11-19 mm;
  • giant – for the stomach – 30 mm or more; for the duodenum – 20 mm or more.

According to the International Classification of Diseases (ICD-10) [13] , ulcers are divided into:

  • acute ulcer with bleeding;
  • acute ulcer with perforation (perforation);
  • acute ulcer with bleeding and perforation;
  • acute ulcer without bleeding and perforation;
  • chronic or unspecified bleeding ulcer;
  • chronic or unspecified ulcer with bleeding and perforation;
  • chronic ulcer without bleeding and perforation;
  • unspecified ulcer without bleeding or perforation.

These variants of the course of peptic ulcer disease differ in symptoms and severity of clinical manifestations. Depending on them, treatment can be carried out both on an outpatient basis using diet and pills, and in a hospital in the form of emergency operations.

Complications of stomach ulcers

Ulcer bleeding is the most common complication [14] . It is dangerous in that if the vessel wall is damaged in the ulcer and the beginning of bleeding, the person does not feel anything, especially if the ulcer was painless. When the stomach fills with blood, reflex vomiting occurs. Thus, the disease manifests itself. Then the patient’s symptoms of blood loss increase:

  • blood pressure decreases;
  • pulse quickens;
  • the skin turns pale and covered with sweat;
  • weakness is growing;
  • shortness of breath appears, despite a decrease in physical activity.

When the ulcer defect and the source of bleeding are located in the lower parts of the stomach or in the duodenal bulb, symptoms of blood loss first appear, and then liquid tarry (“black”) stools appear.

Perforation of the stomach wall – the formation of a through hole when the ulcer spreads through all layers of the stomach wall. Through this opening, the contents of the stomach flows into the abdominal cavity and causes peritonitis – a total inflammation of the tissues of the abdominal cavity. The moment of perforation is accompanied by a sharp extremely intense pain, up to painful shock, a decrease in blood pressure, and a sharp pallor of the skin. Subsequently, intoxication (symptoms of “poisoning”) and multiple organ failure increase. Without emergency medical care, with such a complication, a person dies.

Ulcer penetration can also complicate the course of the disease. If the ulcer is located on the wall of the stomach, which borders another organ – the pancreas or the intestinal wall, then it can spread to this adjacent organ. Then, the first manifestations of gastric ulcer may be gradually increasing symptoms of inflammation in the secondary affected organs.

Malignancy is the degeneration of a peptic ulcer into stomach cancer with all the ensuing consequences. The risk of such a degeneration appears if the ulcer exists for a long time.

Cicatricial stenosis is a dangerous consequence of ulcer healing. As a result of scarring, the lumen of the stomach or duodenum can significantly narrow, up to the difficulty or impossibility of the passage of solid and liquid food through it. In this case, the patient loses weight, is quickly depleted and gradually dies from dehydration and hunger.

Diagnostics of the stomach ulcer

Diagnosis of a typical stomach ulcer is quite simple and is carried out by a therapist or gastroenterologist. During the examination, the doctor determines the general condition of the patient, clarifies the complaints, the nature and characteristics of the course of the disease, and during palpation specifies the boundaries of painful zones and their nature [16] . If necessary, the doctor prescribes blood tests and instrumental examinations in order to form a clear idea of ​​the patient’s health status and develop the most optimal treatment plan.

It is more difficult to establish a diagnosis with an atypical or painless ulcer , especially when complications appear in the form of penetration – the spread of an ulcer to a neighboring organ.

The first sign of an asymptomatic or “dumb ulcer” is often its complication in the form of bleeding, due to which the patient is urgently admitted to a surgical hospital, where a medical examination is carried out, an anamnesis is found, blood is taken for tests, if necessary, EGDS, ultrasound are performed, x-ray.

The optimal method for diagnosing peptic ulcer disease (and with its painless course – the only and effective way) is a planned endoscopic examination – esophagogastroduodenoscopy (EGDS) [15] . The EGDS procedure is safe, lasts a few minutes, and is accompanied by unpleasant, but quite bearable sensations. As a result of the examination, there is comprehensive information about the state of the upper gastrointestinal tract, the presence and nature of inflammatory and erosive-ulcerative processes, as well as the appearance of neoplasms.

Endoscopic examination

With the help of special technologies during EGDS, the acidity of gastric juice and the presence of H. Pylori infection are determined, small fragments of the gastric mucosa are taken from neoplasms for histological examination – to determine the type of tumor.

When treating a patient with signs of gastric bleeding, using EGDS, the sources of bleeding are determined, which can be immediately eliminated, allowing the patient to avoid serious surgical interventions [2] [7] [9] [10] .

Stomach ulcer treatment

A therapist or gastroenterologist deals with the treatment of peptic ulcer disease. It aims to eliminate symptoms, heal ulcers and eliminate the cause of the disease through diet, lifestyle changes and medication.

To get rid of the ulcer-provoking H. pylori infection, the doctor prescribes antibiotics, and to reduce the acidity of the gastric juice – acid-lowering drugs, etc. drugs similar to the “culprit” of the disease, which do not have an ulcer-forming effect [14] .

It is very important for peptic ulcer disease to give up addictions, first of all – from smoking and excessive alcohol consumption. This will eliminate the risk of complications.

Also, during treatment, you need to adhere to a certain diet – diet number 1. It involves good nutrition, divided into 5-6 meals a day. The use of strong irritants of gastric secretion (ketchup, hot spices), rough foods and dishes is limited. Food is prepared mostly pureed, steamed or in water, fish and non-coarse meats are served in chunks. Very cold and hot dishes are excluded from the diet. The intake of table salt is limited.

After restoring the balance between aggressive and protective factors, ulcers heal on their own within 10-14 days.

In case of complications of peptic ulcer disease ( perforation, stenosis, uncontrolled, repeated bleeding ) or in case of ineffectiveness of drug therapy, treatment is performed surgically [14] . However, surgery is always a big risk. With peptic ulcer disease, it is performed as a last resort. If it can be avoided without letting the disease develop, then it is better to use this opportunity [2] [5] [6] [10] .

Forecast. Prevention

The prognosis for peptic ulcer disease depends on the patient himself. With a healthy lifestyle, proper nutrition, respect for your health, the likelihood of a stomach ulcer is extremely low. Violation of sleep and nutrition, overwork, stress, neglect of routine medical examinations, ignoring one’s own seemingly insignificant discomfort often lead to the development of complicated forms.

It is much easier, faster and cheaper to prevent peptic ulcer disease than to treat its developed forms and complications. To this end, the World Health Organization (WHO) recommends, starting from the age of 25, annually to undergo preventive examinations by a general practitioner or gastroenterologist. If the relatives had a peptic ulcer, then, regardless of complaints, EGDS was recommended with the determination of gastric acidity, clarifying biopsies to determine H. Pylori infection and histological examination of suspicious areas. It is held every two years. In the absence of complaints, preventive complex EGDS is indicated every two years after 35 years. Identified at the same time and promptly treated in the early stages of the disease – gastritis, duodenitis, H. Pylori infection – will avoid the development of not only ulcerative processes, but also oncological diseases.

There are three stages of prevention :

  • primary – when there is no disease, but there is a risk of its development;
  • secondary – aimed at preventing the progression of an already existing disease;
  • tertiary – carried out after the development of complications.

Primary prevention rules :

  1. Adhere to a certain daily calorie content of food: carbohydrates – 50% or more, proteins – 30%, fats – 15-20%. It is important to consider physical activity, height and weight. You need to eat often, in small portions. Eliminate “hungry” and “mono-diets”. It is highly undesirable to consume alcohol, soda, fatty, fried, smoked food, canned food, fast food. It is recommended to eat cereals, soups, boiled meat and fish, vegetables and fruits. Moderate use of muffins and sweets is allowed.
  2. Adhere to a healthy lifestyle: give up bad habits, be physically active, sleep at least 7 hours a night. Avoid stressful situations, learn to perceive them correctly.
  3. Regularly visit a doctor as part of a medical examination and eliminate foci of chronic infection, including timely treatment of caries , as it reduces the general immunity, which facilitates the “work” of any infection, including H. Pylori.
  4. Starting from the age of 25, once every two years, undergo a planned complex endoscopic examination – EGDS with the definition of H. pylori.

In secondary and tertiary prevention, all rules from the first stage are added:

  1. Strictly adhere to diet No. 1. The use of indigestible coarse food, meat, fish and mushroom broths, strong tea and coffee, muffins, chocolate, fresh sour fruits, spicy vegetables – turnips, radishes, radishes, onions is excluded. Food should be steamed, boiled or baked (no crust) in pureed form. It should be warm, neither cold nor hot. The portions should be small. It is advisable to drink mineral water, which reduces the acidity of the stomach.
  2. Eliminate any causes of exacerbation of the ulcer, for example, chronic gastritis .
  3. Carefully follow medical instructions.

From all this it follows that in most cases the development of peptic ulcer disease and its complications can be easily avoided if you are a medically competent person, listen to the recommendations of doctors, official authoritative medical sources and not neglect routine examinations.

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