THE SORE THAT NEVER HEALED.

THE SORE THAT NEVER HEALED.

Writing this article got me a little emotional. Let me share a tragic story with you about the sore that never heals with wound dressing. It was in the early hours of the day, around 10am in the month of May or June, 2023. I cannot recall the exact month. It was actually a weekday and I was dressed up in my trouser and shirt with my laboratory coat on and with my name boldly embroided in it at the top right corner. Together with about three or four of my group members, we spotted a young lady at the entrance of the ward, just to the right. As student doctors, the senior doctor who doubles as the supervisor divided us into groups and instructed us to take histories from the patients.

She was alert and conscious, ready to talk to us and looked like she was recovering and would be discharged a day or two after. She introduced herself as Quincillin, a 27 year old lady who is an upcoming make-up artist. The history we took indicated she had an upper gastrointestinal bleeding due to peptic ulcer disease. Honestly, she looked well. I quite remember she showed me her previous pictures on her phone indicating she has lost some weight and a picture of melena stools (dark tarry tools).

A day or two after, I passed by her ward only to see doctors and nurses around her. Quincillin was in cardiac arrest and the physicians did everything possible and eventually resuscitated her. I was there when she opened her eyes. I left to attend to other duties only to hear from a colleague that she passed away later. May her soul rest in perfect peace. It was later that it dawned on me that peptic ulcer is more serious than I ever imagined. The discomfort it brings you, the diet restrictions it comes with not forgetting the number of weeks you have to be on triple therapy. 

Peptic ulcer disease is defined as mucosal breaks in the stomach and duodenum when corrosive effects of acid and pepsin overwhelm mucosal defense mechanisms. Sites for peptic ulcer include stomach, duodenum (usually 1st part), oesophagus ,small bowel adjacent to gastroenteric anastomoses and within a Merkle’s diverticulum. One main way or differentiating between duodenal and peptic ulcer is the timing and intensity of the pain. For stomach ulcer, the pain increases upon eating but for duodenal ulcer, the pain goes down or decreases after eating.

 Causes of peptic ulcer include:

1.Helicobacter pylori, a gram negative urease producing organism. It is associated with 50 percent of peptic ulcer cases.

2.Use of Non-Steroidal Anti-Inflammatory Drugs(NSAIDS) and aspirin.15 to 25 percent of people who are chronic users of NSAIDS and aspirin develop peptic ulcer disease. These drugs inhibit prostaglandins which protect the stomach lining from the corrosive effects of the acid made in the stomach.

3.High acid producing states as in the case of genetic composition, stressful states including the use of steroids and in malignancies like gastrinoma.

4.Some are just idiopathic, that is, there is no specific cause.

Risk of developing peptic ulcer disease is increased with history of peptic ulcer diseae or dyspepsia, age greater than 60 years, concomitant corticosteroid use,high dose or multiple steroid use,serious co-morbid medical illness and cigarette smoking which doubles the risk.

PATHOPHYSIOLOGY OF PEPTIC ULCER DISEASE

The parietal cells of the stomach has a proton pump fueled by calcium activated by the histamine(h2) receptor. The pump sends out hydrogen into the stomach and potassium back into the parietal cell. This explains why most drugs to combat peptic ulcer disease are targeted against the proton pump or the histamine receptor. Most common symptoms: epigastric pain and dyspepsia.Others include burning sensation, chest pain, nausea, vomiting. The commonest sign is epigastric tenderness. Alarming Symptoms include weight loss, early satiety,persistent vomiting, epigastric mass, and inadequate response to treatment.Recurrent and untreated peptic ulcer disease may cause rupture of blood vessels at the site of the ulcer leading to bleeding. This bleeding, if it is above the junction between the duodenum and the jejunum, presents as upper gastrointestinal bleeding. This manifests as melena tools which is dark tarry stools as in the case of Quincillin. People with upper gastrointestinal bleeding presents with anemic symptoms such as dizziness, palpitations, sweating,fainting,hypotension which can cause cardiac arrest in extreme cases. Sometimes, a peptic ulcer disease may be mistaken for 

Gastroesophageal reflux disease (GERD)

Gastritis

Non-ulcer dyspepsia

Gastric malignancy

Acute Myocardial infarction

Pancreatitis

Pancreatic ulcer

Cholecystitis

The gold standard of investigation is upper gastrointestinal endoscopy. Endoscopy helps your physician to know the actual site of the ulcer (whether it is in the stomach or duodenum) and to also take biopsies if the need be. Your physician may order for Helicobacter pylori test where a very small portion of your stool may be requested by the laboratory scientist. Serum antibody test, Stool antigen test which can be used to confirm irradication, rapid urease testing for Campylobacter-like organism (CLO) for patients undergoing endoscopy and Carbon-labelled urea breath testing which is the most accurate non-invasive test and best for post-irradication assessment.

Treatment includes acid suppression which is the mainstay of therapy. This can be achieved with proton pump inhibitors like Omeprazole, Lansoprazole, Rabeprazole, Esomeprazole.Histamine receptor antagonists like Ranitidine, Famotidine can be used. Make sure to avoid NSAIDS and aspirin and sometimes misoprostol may be used for mucosal protection. Bismuth Sulphate: helpful but no longer used as a regimen for H. pylori irradication. Additional treatment methods are:

Sucralfate: coats lining without suppressing acid production

Antacid: supportive, symptom relief

Non-pharmacological eg.

Dietary pattern changes;avoid or reduce alcohol and pepper in diet

Smoking cessation

Stress management

Surgical: surgery comes in when you have a gastrointestinal bleeding or Zollinger Ellison Syndrome

Let us look at some of the complications of peptic ulcer disease. This include upper gastrointestinal bleeding which we have already discussed. This presents with symptoms of anaemia, coffee-ground vomitus, that is vomitus may have blood in it, melena stool in about 70% and bloody faeces in brisk bleeding. Another complication is gastric outlet obstruction which usually occurs when the ulcer is close to the exit point of the stomach. Repetitive ulcers cause pain and healing in which a scar tissue may be formed over there reducing the size of the exit point of the stomach. The pancreas lies just behind the stomach and in some cases the ulcer can penetrate deep into the pancreas causing pancreatitis. The last complication is gastric or duodenal perforation which occurs when the ulcer buries deep into the wall of the stomach or duodenum causing a perforation If you have been diagnosed with peptic ulcer, kindly follow your doctor’s advice and adapt some lifestyle changes. Eat regularly, avoid alcohol, smoking and pepper in diet. Lastly, reduce or avoid citric fruits like pineapple and oranges.