Summary - 

Location: occur in the stomach and upper duodenum

Ulcerations of the gastric or duodenal mucosa that penetrate the submucosa. Usually occur in the antrum of the stomach or in the first few cm of the duodenum. Erosion may proceed to other levels of tissue and can eventually perforate. Breakdown in the tissue allows for continued damage by the highly acidic environment of the stomach as well as damage from other secretions of the stomach, such as pepsin. 

Helicobacter pylori (H. pylori) is a common cause of ulcers. H. pylori lives under the mucous layer of the stomach and attaches to mucus-secreting cells lining the stomach. 

The etiology of PUD also involves factors that may decrease mucosal integrity, such as a reduction of protective prostaglandins (a group of lipids made at sites of tissue damage or infection that are involved in dealing with injury or stress) through the use of NSAIDs or alcohol, excessive glucocorticoid secretion or steroid medication, and factors that decrease the blood supply, such as smoking, stress, or shock. Factors that increase acid secretions including certain foods, rapid gastric emptying, or increased gastrin secretions, also contribute to the development of PUD. 

The most common symptom related to ulcers is epigastric pain(upperabdominal pain). Patients may complain of abdominal pain and a burning sensation, which may be precipitated by certain types of foods or accentuated by food intake. For others, epigastric pain may be relieved by food intake due to its ability to dilute any irritants. For a duodenal ulcer, pain may occur 90 minutes to 3 hours after eating, and is usually relieved within minutes either by eating or by the use of antacids. *Unfortunately, partial neutralization of gastric acid is followed by a rebound of gastrin release, causing additional stimulation of HCL and probably more pain.

The presence of blood in stool or vomit + changes in hemoglobin or hematocrit may be indicative of active bleeding from the ulcer + changes in WBC will be consistent with an active infection.

Treatment - 

Antibiotics: If the cause of ulcers are due to H. pylori, therapy includes medications (such as PPIs) with antibiotics

Medication: Other treatment focuses on the use of medication to suppress acid secretion, which will ultimately promote healing of the ulceration. Such medications include antacids, PPIs, histamine blocking agents (H2 blockers), prokinetic agents, and mucosal protectants. 

o  Because salicylates (aspirin) and NSAIDs are linked to increased gastric irritation, these medications should not be taken by someone with PUD.

Surgery: For those unresponsive to treatment or supper from complications like bleeding, perforation, or obstruction, surgical resection may be necessary. 

Nutrition intervention: goals include supporting medical treatment, maintaining or improving nutritional status, and providing a diet that minimizes symptoms of PUD.

Restricting foods that may increase acid secretion or cause direct irritation to gastric mucosa: these foods include black and red pepper, caffeine, coffee (including decaffeinated), and alcohol.  Restricting acidic juices or other foods is not consistently warranted unless the patient identifies intolerance to them.

o  Patients should not lie down after eating and avoid eating large meals close to bedtime. Smaller, more frequent meals may be better tolerated. 

o  Foods not recommended if symptomatic: cola, coffee, tea, cocoa, alcohol, 2% or whole milk, cream, high fat yogurt, chocolate milk, fried meats, bacon, sausage, pepperoni, salami, bologna, hotdogs, and desserts high in fat or fried, such as pastries and doughnuts. 

Factors that decrease mucosal integrity (cause gastric irritation): NSAIDs, alcohol, glucocorticoid secretion, or steroid medications

Factors that decrease blood supply: smoking, stress, shock

Factors that increase acid secretions: Certain foods, rapid gastric emptying, increased gastric secretions