Upper gastrointestinal bleeding is a common clinical problem, afflicting approximately one out of every thousand people each year. In most cases, bleeding stops spontaneously. However a minority rebleeds or continues to bleed despite attempts at stopping it. Approximately 1 in 20 patients who present with upper gastrointestinal bleeding will die over the course of their hospitalization.
In most cases of upper gastrointestinal bleeding, a source is identified after careful clinical and endoscopic evaluation. In approximately 15% of cases, bleeding originates from esophageal or gastric varices associated with portal hypertension. Varices are dilated tortuous veins. Among cases of non-variceal upper gastrointestinal bleeding, over 50% are caused by peptic ulcers.
Peptic ulcerations are excavated defects (holes) in the gastrointestinal mucosa. They result when the lining of the stomach and intestine succumb to the effects of acid and the enzyme pepsin. The term “peptic ulcer disease” is commonly used to refer to ulcerations of the stomach, duodenum, or both, but peptic ulcers can develop in any portion of the gastrointestinal tract that is exposed to acid and pepsin in sufficient concentration and duration.
In the early part of the 20th century, stress and diet were judged to be important factors for peptic ulceration. Consequently, patients with peptic ulcers were treated with hospitalization, bed rest, and the prescription of “bland” diets. During the 1980s, investigators learned that most peptic ulcerations were associated either with gastric infection by the bacterium Helicobacter pylori or with the ingestion of nonsteroidal anti-inflammatory drugs (NSAIDs). Furthermore, numerous studies showed that if H. pylori infection and NSAID use could be eliminated, then peptic ulceration recurred infrequently. Nevertheless, a substantial minority of patients with peptic ulcerations who have no apparent predisposing factor remains. With the advent of proton pump inhibitors in the 1980s, more potent acid suppression and higher rates of ulcer healing could be achieved.
Approximately 500,000 new cases and 4 million recurrences of peptic ulcers occur in the United States each year and approximately 10% of individuals in Western countries will develop a peptic ulcer at some point during their lifetimes.
Why are bleeding ulcers dangerous?
Peptic ulcerations that burrow into blood vessels can result in life-threatening bleeding. It has been estimated that peptic ulceration is responsible for nearly 50% of all cases of acute bleeding from the upper gastrointestinal tract. As mentioned earlier approximately 1 in 20 patients who present with upper gastrointestinal bleeding will die over the course of their hospitalization. Approximately 140,000 hospitalizations for bleeding peptic ulcers occur each year in the United States, and the death rate is between 5% and 10%.
Free perforation of a duodenal or gastric ulcer into the abdominal cavity can be a catastrophic, life-threatening event. Most patients with this complication are elderly. The perforations are associated with NSAID use in up to one half of cases. Smoking is also associated with perforated peptic ulcer and, in patients younger than the age of 75, smoking appears to be a stronger risk factor for perforation than NSAIDs.
Treatment of peptic ulcers
Uncomplicated peptic ulcers are treated with antacids, histamine receptor antagonists and proton pump inhibitors. Complicated peptic ulcers are treated with blood transfusion, endoscopic therapy and surgery.