Digestive disorders

IV/4.3: Course

Untreated ulcer may undergo spontaneous healing; however reappearance of the ulcer is common within one or two years. The ratio of recurrence is 50 to 80%; it is not always associated with symptoms. The treatment of H. pylori infection changed the natural course of peptic ulcer. Eradication of H. pylori reduced the recurrence of a healed gastric ulcer from 67% to 6%. When no cause of the peptic ulcer could be revealed (ulcers not due to H. pylori or NSAID), there is a higher ratio of recurrence. In elderly patients the healing of ulcers is slower, the ratio of the complications is higher as well, and the time of hospitalization is also longer due to the accompanying diseases. Healing is also delayed when gastric and duodenal ulcers are simultaneously present, and the complications are more common as well. Course and outcome are determined also by the appearance of the ulcer. Giant ulcers show a slower healing . Smoking not only retards healing but also promotes recurrence.

The most important complications of the disease include the development of:

• - bleeding

• - perforation and

• - stricture.

Complications of the ulcer are more common in elderly patients and in those who take NSAID.

Severe complications are extremely rare (less than 1/1000 year of life) in patients who take no NSAID.

• - The most frequent complication of peptic ulcer is bleeding ; it occurs in 15 to 20% of cases . In 20% it develops with no previous symptoms of ulcer. Its development is promoted by association of the peptic ulcer with coagulation disorder, portal hypertension; chronic renal failure; certain medicines including NSAID and corticosteroids, and alcohol consumption. Hemorrhage of the ulcer is the most frequent cause of mortality and surgical interventions in patients with peptic ulcers. The bleeding is self-limited in 70% of the cases.

• - Overt abdominal perforation with no previous history of ulcer may develop in 2 to 10% of cases. Effective inhibition of acid secretion has not reduced the number of ulcer perforations. The risk of developing a perforation is increased by the concomitant taking of corticosteroids or ASA, and the consumption of alcohol. In case of a penetration, perforation occurs not toward the abdominal cavity, but into the neighboring organs (left hepatic lobe, pancreas, pericardium).

• - Stenosis (narrowing) may occur in patients with prepyloric or duodenal ulcer. It is a complication characteristic of the elderly age group. The narrowing of pylorus and bulbar canal is caused by muscle spasm, edema and muscle hypertrophy in the acute period, and by cicatricial healing of the recurring peptic ulcer later.

In patients with gastric ulcer an increased risk of gastric cancer is present in certain ethnic groups (Latinos, Asians), or due to a positive family history, association of H. pylori infection with gastric atrophy, age over 50 years, the lack of a previous or concurrent duodenal ulcer, as well as the giant ulcers of 2 to 3 cm.