The gastric ulcer is one type of peptic ulcer, it has become a concern since the last country. In the past, managed peptic ulcer diseases with surgery was the most common method of treatment. However, the incidence of peptic ulcer and death rate were still high. A peptic ulcer has affected the digestive system which including the stomach, the esophagus and the duodenum. According to the position of the sore, to identity it belongs to gastric ulcer or duodenal ulcer. In developed countries, for instance, the Unite State, one of ten individuals suffer a peptic ulcer, on other other hand, gastric ulcer is frequently seen in Asia country, especially in Japan (Yuan et al., 2006). Three-decade ago, there were over ninety percentage of patients were diagnosed duodenal ulcers, and seventy percents of patients were with gastric ulcers. There are two basic causes which result patients peptic ulcer, one is Helicobacter pylori infection, another is using nonsteroidal anti-inflammatory drugs, such as aspirin.
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In this essay, it will be examined what is gastric ulcer, then describing what are its causative agents. Furthermore, giving more details about disease information, including the symptoms of gastric ulcer, and impacts of the stomach. In addition, it will explain how hosts response when the tissue and organ changes by a gastric ulcer, when human bodies detects the damage how its defense and how the repair mechanism heals damage cells and tissues. In this essay, it also will give more information about the diagnosis methods of gastric ulcer. Lastly, it will then indicate how therapies can be used to against the gastric ulcer.
A gastric ulcer often occurs on the smaller curvature of the stomach. It forms solitary or multiple lesions in the stomach lining (Mardisty, 1921).
In the stomach, it accounts for a natural barrier which is produced by some cells of the inside lining to protect the lining of the stomach and duodenum. It balances the secretion of gastric acid and pepsin. When the balance has been damaged, a gastric ulcer may develop. The characteristic of gastric ulcer may be an acute or chronic but it may recur over and over again. One of the significant character is abdomen pain. However, each patient has the different level tolerance of pain, it is hard to establish a rule to measure the tolerance of pain. Some patients may feel uncomfortable, some of them describe the pain lasts constantly. It depends on their description about the pain, usually it is described like gnawing or burning pain, dull pain, causalgia or twinge (Richards, 1920). Besides that, it is defined that there are two main causes result in a gastric ulcer, one is Helicobacter pylori infection, another is taking non-steroidal anti-inflammatory drugs, both of them damage epithielial cells and the mucus layer of the stomach, then forming the inflammation and tissue lesions. However, it believe that intaking excessive stimulating food or caffeine, or stress may also cause a gastric ulcer. A gastric ulcer does not always reveal abdomen pain or accompany other complication symdroms such as : haematemesis or perforation, therefore, individuals need to do physical checkup regularly to prevent from suffering gastric ulcer.
In the past, it was difficult to identify what is the cause to induce a gastric ulcers. It was assumed that the mucus has been damaged by acid and pepsin to form a surface lesion of the lining of the stomach. It was believed that the causes of gastric ulcer were based on the patient having the disorder of life style or under pressure.
Even thought Helicobacter pylori have been known for a few decades, however, there is no one linked them with gastrointestinal ulcer. This situation lasted until 1981, two Australian doctors ,Dr. Barry J. Marshall and Dr. Robin Warren, they confirmed the Helicobacter pylori is one of the main causative agents which results in gastrointestinal ulcer. (Bauer and Meyer, 2011). They assumed that Helicobacter pylori has degraded the function of mucosa of the stomach and the duodenum. Furthermore, it causes inflammation and erosions inside the lining of the stomach.
It is the advanced breakthrough in the research of gastrointestinal ulcer which has not only led to a change in helping individuals to rethink the definition of them, but also renewed the features in the pathology of the gastrointestinal ulcer.
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According to (Lage et al., 1995) Helicobacter pylori used to call Campylobacter pyloridis before 1990. It is defined as a gram-negative bacterium and microaerophilic microorganism that relies on oxygen to survive. There are approximately half population in the world present Helicobacter pylori. Even it causes gastric ulcer, however, in most of the affected individuals do not express any symptoms. If individuals do not accept antibiotic therapy, Helicobacter pylori can exist in human stomach during the entire life (Rathbone et al., 1986).
Even though human absorb many microorganisms daily, but many of them cannot dominate the stomach, excepting Helicobacter pylori. H. pylori are taken in with water or food. In human stomach, the individuals gastric luminal pH is less than 2, which forms a natural barrier to prevent bacteria proliferation within the gastric lumen (Algood and Cover, 2006). The gastric mucosa produces a number of materials such as gastric acidity, lactoferrin and antibacterial peptides which can constrain the multiplication of bacteria (Yuan et al., 2006). It prevents multiplication of bacteria within the stomach lumen. H. pylori is usually defined as a noninvasive bacterial organism, because of it does not penetrate the epithelial barrier usually.
Visualizing the Helicobacter pylori bacteria with an electron microscope, it showed that they are curved rod shape. They have smooth surfaces and around four to six flagella, each flagella is with a terminal bulb, that is a significant character of Helicobacter pylori (Rathbone et al., 1986). Flagella enable H. pylori to traverse the gastric mucus layer because of their motility (Algood and Cover, 2006). Some of them may attach to surface of stomach epithelial cells and internalized by epithelial cells (Algood and Cover, 2006). They were detected in many patients who are with gastric ulcer, so that H. pylori is considered to be the primary causative agent in most gastric ulcer cases.
Besides Helicobacter pylori, another cause which results in gastric ulcer is non-steroidal anti-inflammatory drugs, such as aspirin, which causes gastrointestinal mucosal damage, erosions, ulcers , ulcer complication and bleeding (Yuan et al., 2006). It slows the healing process of gastric ulcer. According to (Ji and Hu, 2006), NSAIDs inhibit the activity of cycloosygease (COX), and also indirectly inhibit the products of prostaglandin, prostacyclin and thromboxanes to relieve the inflammatory. However, meanwhile, it inhibits the activity of COX1, furthermore, affecting the prostaglandin of mucos membrane (Ji and Hu, 2006).
Symptoms of gastric Ulcer
Scanning human gastric epithelial cells by an electron microscope, on the left hand side of the picture is non-infected cells, on the right hand side of the picture which shows infected epithelial cells. (Bauer and Meyer, 2011).
Although ulcers do not always reveal symptoms, many patients with gastric ulcers felt epigastric pain after taking food one to three hours. The most common ulcer symptom is a gnawing or burning pain in the abdomen. In some cases, patients accompanied severe complications which including haematemesis, bleeding even shock. Moreover, a gastric ulcer may cause by the increasing of digestive juice, which imbalance the acid and pepsin production an excessive amount than they usually do, in the meantime, a gastric ulcer may develop.
Helicobacter pylori induces the gastric ulcer through acid stimulating. Besides, the psychological factor such as intensity also can result a gastric ulcer.
Gastric ulcers are caused by an imbalance between stomach acid, an enzyme called pepsin which is the natural defenses of the stomach's lining. This imbalance leads to inflammation, which can be worsened by taking aspirin and nonsteroidal anti-inflammatory medications (NSAIDs) such as ibuprofen, and aspirin.
When a patient has these specific symptoms, they can help to diagnose the gastric ulcer. The patient who has a gastric ulcer with epigastric pain is worse during the night and may awaken the patient up (Damjanov, 2009). The pain can be relieved by antacids or milk. He or she felt pain after taking food two to three hours. Some of gastric patients may have hemorrhage syndrome, because of their stomach have been damaged by lesions. Bleeding is a significant character of an acute gastric ulcer. It may cause patients haematemesis and melaena. Following that, patients may accompany fainting and anemia (Bolton, 1922).
There are two main causes of the gastric ulcer, one is Helicobacter pylori another is long-term using nonsteroidal anti-inflammatory drugs.
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Disease information ââ‚¬" organ/tissue/cellular level (total 30 marks)
What should be included:
A detailed explanation of the host responses at the cell, tissue and organ levels. Include information on cellular responses and adaptations, and impacts on cellular structure and function.
Explain host defense and repair mechanisms, if any. Explain if the host responses are transient/reversible or if these causes permanent changes to the cells/tissues. Include information on the pathology and/or cellular features sought for diagnosis.
The gastric mucosa produces a number of materials such as gastric acidity, lactoferrin and antibacterial peptides which can constrain the multiplication of bacteria. The function of the mucosal barrier is to support normal blood flow, mucus secretion, and protect the surface of the mucosa . A gastric ulcer may also cause by the increasing of digestive juice, which imbalance the acid and pepsin production an excessive amount than they usually do, in the meantime, a gastric ulcer may develop. It was assumed that due to the mucus has been damaged by acid and pepsin to erode mucus membrane, furthermore, to form a surface lesion of the lining of the stomach (Damjanov, 2009).
Not only infected H. pylori but also NSAIDs affect the epithelial cells of the stomach, since that, they have been damaged ,and then to form one or multiple sores inside of the stomach lining. Moreover, most of patients who have gastric ulcer may feel discomfortable in their abdomen, in some cases, patients accompanied severe complications which including haematemesis, bleeding even shock. When the patient has those significant symptoms which may help to diagnose the gastric ulcer or even other peptic ulcers.
There are two types of acute gastric ulcers:
Firstly, its character is there is a variety of sizes of the lesions can be seen with x-rays, which opens an artery on. However, they are hardly involved the peritoneum. The host can heal these lesions by-self that may take a couple of weeks, and then they are impaired by the organ mechanism.
Secondly, when the lesions become worse, these lesions penetrate through the mucus layer (Algood and Cover, 2006). Furthermore, they may expand the surface of the mucous membrane to form a large scale ulcers. Since that, the chronic ulcer may develop the acute ulcer, but there is a few of the differences which are some of them may heal gradually, but still a large portion of them are have no capacity to recover themselves. Some patients are not aware of the gastric ulcer disease before the specific syndromes occur. They may occur accidentally without accompanying any syndromes. The chronic gastric ulcer may last a few months or even years (Bolton, 1922).
Moreover, as mentioned previously, H. pylori infection causes gastric ulcer as well. H. pylori can exist within the human body for a long-term period without being quenched by the immune system (Bauer and Meyer, 2011). It attacks the host immune system and causes chronic , indolent inflammations. Also it reduces the thickness of the mucus layer, further to damage the mucosal defense system. Then weakening mucosal blood flow, and interacting with the gastric epithelium throughout all stages of the infection. On the other hand, it stimulates gastric acid secretion. It induces inflammation, which increases parietal-cells mass and the capacity of acid secretion (Yuan et al., 2006). Gastric ulcers are caused an imbalance of stomach acid and an enzyme whose name is called pepsin, and the natural defenses of the stomach's lining. This imbalance leads to inflammation, which can be worsened by aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs).
However, some patients are not aware the gastric ulcer, because the gastric ulcer may exist in their bodies without any symptoms. Since that, these damages cells have developed a large scale of lesion in the stomach, gradually, these lesions may start to penetrate through the entire muscular layers, and to diffuse from the peritoneal cavity to cause peritonitis by a great number of adhesions walling off. Furthermore, the perforation may further extend becoming a penetration (Richards, 1920). Moreover, deep ulcers may penetrate through the gastric wall into the adjacent organs, which results other organs inflammation and lesion forming, for instance, duodenal ulcer (Damjanov, 2009).
Diagnostic methods ââ‚¬" efficacy, advantages, constraints and/or problems (total 15 marks)
In the past, it admitted that there is a difficulty to diagnose the gastric ulcer, because of the uncompleted etiology. In order to overcome this obstacle, using the x-rays can locate to the position of the lesion, and accompany the specific symptom to diagnose gastric ulcer. Tenderness is a significant sign in gastric ulcer diagnosis. The hematemesis and perforation were the primary indication. Since that, recurring pain and vomiting were also defined as the symptom of gastric ulcer. However, it had been debated that due to there is a variety of pains in the history,
The character of gastric ulcer is the relation of pain to food, some patients felt worse after taking food (Mardisty, 1921). On the other hand, some patients felt constant pain or not affected after taking food.
Gastric ulcers are caused an imbalance of stomach acid and an enzyme whose name is called pepsin, and the natural defenses of the stomach's lining.
This imbalance leads to inflammation, which can be worsened by aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs).
There are many high risky factors may cause gastric ulcer including:
Taking aspirin and nonsteroidal anti-inflammatory drugs, Helicobacter pylori infection, chronic gastritis, smoking, age increase, certain blood clotting problem.
However, tress does not worsen gastric ulcers.
When a patient is with these specific symptoms, these can help to recognize the gastric ulcer. The patient may awaken up at night with abdominal pain. The pain can be relieved by antacids or milk. He or she felt pain after taking food two to three hours. Vomiting blood, especially. Blood in stools or black. Weight loss and felt fatigue.
The history provides a clue when patients are with haematemesis or perforation.
Perforation means the stomach wall may be penetrated by gastric ulcers. The ulcers have perforated through all of the muscular layers, and is separated from the general peritoneal cavity and cause peritonitis. Moreover, when the ulcers penetrate through the stomach wall into the nearby organs, which is called penetration. That is the typical gastric ulcer syndrome (Richards, 1920).
There are a number of symptoms which including epigastric pain, nocturnal pain, or feeling discomfortable after taking food. Those are helpful to diagnose gastric ulcer disease. Some of patients vomit blood. However, there is no specific symptom can used to reorganize the difference the infection cause is from NSAID or H. pylori infection (Yuan et al., 2006).
The x-ray has not only advantages in diagnosis, because it provides information of an accurate diagnosis,but also benefit to locate the lesion of gastric ulcer.
There are several techniques are used to detect the H. pylori infection nowadays.
H. pylori G Enzyme-Linked Immunosorbent Assays (ELISA) can be used to detect the presence of Helicobacter pylori in patientsââ‚¬â„¢ serum. It relies on the anti-gent to detect the anti-body. Serology test only can be used in vitro diagnosis, when it detects the presence of H. pylori the reagent will reveal a interaction but it cannot identify active infection (Aro et al., 2006).
Before the advanced diagnostic techniques are developed, the biopsy still is the most commonly used in many laboratories.
According to a number of clinical studies research, usually these biopsy samples were obtained from patients who are with gastric ulcer to diagnose H. pylori infection. They were stained with Giemsa to observe the presence of bacteria.
The endoscopy relies on a device which made of a small and flexible tube with a light and a camera lens at the end to examine the epithelial cell changes of the digestive organs. It is helpful to differentiate an accurate gastric ulcer and or ulcer complication. It is efficient to control bleeding of the stomach (Aro et al., 2006).
Non endoscopic tests include the C-urea or C- urea breath test. UBT is the most efficient method which used isotopes to detect an active infection. The sensitivity and specificity of UBT may be inhibited by PPI or antibiotic treatment .
Therapy ââ‚¬" effects on cells and tissues (total 10 marks)
Due to H. pylori infection is the most common cause in patients who are with gastrointestinal ulcers. Eradication of H. pylori therapy accounts for antimicrobial agents combined with antisecretory drugs. It admitted that eradication of H. pylori treatment is efficiently for many patients who has duodenal ulcers. However, there is no significant effect on ulcer healing. To compare to the healing rate of gastric ulcer and duodenal ulcers, the former performance was lower than the latter. It can be assumed that even some gastric patients cause by H. pylori infection, however, that does not mean it will have the same effect as duodenal ulcer healing.
There is no evidence to show that eradication of H. pylori accelerate ulcer healing or prevent ulcer recurrence (Ji and Hu, 2006).
Proton pump inhibitor (PPI) is used treat for gastric ulcer. It remains the pH at 6 within the stomach and block stomach acid production by stopping the stomach's acid pump.In order to eliminate the H. pylori, a triple therapy which contains a proton pump inhibitor, amoxicillin, and clarithromycin. It has a remarkable effect to reduce the recurring rate of gastric ulcer which has been proved in a number of clinical studies.
Duo to the treatment with clarithromycin has been used widely, the rate of H. pylori infection has been reduced than ever (Hiraishi et al., 2010).
Stop taking NSAIDs, it has been a concern that it causes gastrointestinal mucosal damage, erosions, ulcers , ulcer complication and bleeding. Surgery- while the medication and endoscopy do not work with the patients , they may need to do surgery to remove the lesion tissues of the stomach (Aro et al., 2006).
Conclusions (total 10 marks)
To sum up, gastric ulcer is defined as a type of gastrointestinal ulcer. Due to the development of treatment and therapies, patients healed within a few couple of weeks. There are two main causative agent one is the H. pylori infection, another is the NSAIDs use. The former result in the mucus layer has been damaged further forming lesions on the stomach lining. There are two kinds of gastric ulcer, one is acute gastric ulcer which accompanies pains and complications such as haematemesis and perforation, another is chronic gastric ulcer, it may cause small lesion and epithelial cell damages for a long time until patients start feeling uncomfortable with abdomen pain and complications.
Ulcer does not always reveal symptoms, but most of gastric ulcer patients may feel abdomen pain sometimes is the significant character of gastric ulcer, furthermore, in some cases, it causes serve complication such as haematemesis and perforation.
Due to the discovery of the causative agent of gastric ulcer which is H. pylori and concluding inappropriately using NSAID, nowadays, there are more detection methods are developed, such as x-ray, endoscopy and serology test. Those are helpful and efficient in diagnosis the gastric ulcer. From that, after many laboratory experimental research and clinical tests, gastric ulcer can be cured well by medical therapy and surgery. Even though it occurs sometimes in many individuals, however, the incidence and death rate have been reduced and controlled than ever.