Ulcers (Digestive)

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Definition

In general, an ulcer is any eroded area of skin or a mucous membrane, marked by tissue disintegration. In common usage, however, ulcer is usually used to refer to disorders in the upper digestive tract. The terms ulcer, gastric ulcer, and peptic ulcer are often used loosely and interchangeably. Peptic ulcers can develop in the lower part of the esophagus, the stomach, the first part of the small intestine (the duodenum), and the second part of the small intestine (the jejunum).

Description

It is estimated that 2% of the adult population in the United States has active peptic ulcers, and that about 10% will develop ulcers at some point in their lives. There are about 500,000 new cases of peptic ulcer in the United States every year, with as many as 4 million recurrences. The male/female ratio for ulcers of the digestive tract is 3:1.

The most common forms of peptic ulcer are duodenal and gastric. About 80% of all ulcers in the digestive tract are duodenal ulcers. This type of ulcer may strike people in any age group but is most common in males between the ages of 20 and 45. The incidence of duodenal ulcers has dropped over the past 30 years. Gastric ulcers account for about 16% of peptic ulcers. They are most common in males between the ages of 55 and 70. The single most common cause of gastric ulcers is the use of nonsteroidal anti-inflammatory drugs, or NSAIDs. The widespread use of NSAIDs is thought to explain why the incidence of gastric ulcers in the United States is rising.

— Rebecca J. Frey

Dictionary: ul·cer  (ŭl'sər)

1. A lesion of the skin or a mucous membrane such as the one lining the stomach or duodenum that is accompanied by formation of pus and necrosis of surrounding tissue, usually resulting from inflammation or ischemia.
2. A corrupting condition or influence.

[Middle English, from Old French ulcere, from Latin ulcus, ulcer-.]

A lesion on the surface of the skin or a mucous membrane characterized by a superficial loss of tissue. Ulcers are most common on the skin of the lower extremities and in the gastrointestinal tract, although they may be encountered at almost any site. The diverse causes of ulcers range from circulatory disturbances or bacterial infections to complex, multifactorial disorders. The superficial tissue sloughs, leaving a crater that extends into the underlying soft tissue, which then becomes inflamed and is subject to further injury by the original offender or secondary infection.

Peptic ulcer is the most common ulcer of the gastrointestinal tract and refers to breaks in the mucosa of the stomach or the proximal duodenum that are produced by the action of gastric secretions. It is still unknown why peptic ulcers develop. However, with rare exceptions, a person who does not secrete hydrochloric acid will not develop a peptic ulcer. Ulcers of the stomach tend to develop as a result of superficial inflammation of the stomach. These individuals tend to have normal or decreased amounts of hydrochloric acid. By contrast, most individuals with peptic ulcers of the proximal duodenum secrete excessive amounts of acid. Importantly, a bacterium, Helicobacter pylori, has been isolated from the stomach of most people with peptic ulcers and is thought to play a causative role. Although stress has been anecdotally related to peptic ulcers for at least a century, serious doubt has been cast upon this concept. See also Inflammation.

Ulcerative colitis is a disease of the large intestine characterized by chronic diarrhea and rectal bleeding. The disorder is common in the Western world, occurring principally in young adults. Its cause is not known, but there is some evidence for a familial predisposition to the disease.

Other ulcers of the gastrointestinal tract are caused by infectious agents. Bacterial and viral infections produce ulcers of the oral cavity. Diseases such as typhoid, tuberculosis, and bacillary dysentery and parasitic infestation with ameba lead to ulcers of the small and large intestines. Narrowing of the arteries to the legs caused by atherosclerosis, particularly in persons with diabetes mellitus, often causes ulcers of the lower extremities. See also Arteriosclerosis; Bacillary dysentery; Diabetes; Tuberculosis.

An erosion of an epithelial surface — the skin, or any of the internal linings (mucous membranes) that are in continuity with the skin at the body orifices. Damage may be physical, chemical, due to failure of blood supply or to infection. Peptic ulcer may be gastric or duodenal — affecting the mucous membrane of the stomach or of the duodenum, attributed to the effects of stomach acid, either when it is in excess, or when the normal defences against damage from it are lacking; now known to be linked with infection by Helicobacter pylori. Oesophageal ulcer is related to reflux of stomach contents. Underlying blood vessels can be eroded, with consequences that can be either insidious, or catastrophic in the case of peptic ulcers; bleeding is readily evident if blood is vomited (haematemesis), but less immediately so if it moves on down the gut to appear (in an altered state) in the faeces (melaena). Less dramatic bleeding can be detected by a test for occult blood in the stool. At worst erosion may penetrate right through the wall — most commonly of the duodenum — causing a perforated ulcer, and escape of gut contents leads to peritonitis.

Ulceration of the skin can occur on the legs as a complication of varicose veins, or of poor circulation due to arteriosclerosis. Bedsores are ulcers caused by prolonged pressure and immobility. Some types of skin cancers or other skin diseases can form ulcers. Aphthous ulcers are small painful erosions of the mucous membrane in the mouth. Without the protection of an intact surface, ulcers from any cause can become deeper due to injury or infection.

— Sheila Jennett

A crater-like lesion of the skin or a mucous membrane resulting from tissue death associated with inflammatory disease, infection, or cancer. Peptic ulcers affect regions of the gastro-intestinal tract exposed to gastric juices containing acid and pepsin: gastric in the stomach and duodenal in the duodenum. Usually treated with antagonists of histamine receptors or inhibitors of gastric acid secretion. Often caused by infection with Helicobacter pyloris.

A loss of covering epithelium from the skin or mucous membranes, causing gradual disintegration and necrosis of the tissues.

For more information on ulcer, visit Britannica.com.

Lesion or erosion of the skin or mucous membrane (e.g. of the stomach).

An inflamed open sore on the skin or mucous membrane. An ulcer may form in the inner lining of the stomach or duodenum, interfere with digestion, and cause considerable pain.

A local defect, or excavation of the surface of an organ or tissue, produced by sloughing of necrotic inflammatory tissue. They occur in all organs and tissues and are to be found under those headings, e.g. abomasal, corneal, gastric.

• button u. — see button ulcer.
• callous u. — see set-fast (2).
• collagenase u. — a rapidly expanding, erosive (‘melting’) corneal ulcer, seen particularly in brachycephalic breeds of dogs.
• Curling's u. — acute ulceration of the stomach or duodenum seen after severe burns of the body in humans.
• decubitus u. — see decubitus ulcer.
• dendritic u. — linear, branching pattern of ulceration on the cornea; characteristic of herpesvirus infections. See also herpetic keratitis.
• eosinophilic u. — see eosinophilic ulcer.
• gastroduodenal u. — common in foals 1–3 months old. Many are asymptomatic. Clinical cases manifest by mild, intermittent colic. See also gastric ulcer, duodenal ulcer.
• geographic u. — a large, superficial, irregularly shaped corneal ulcer, typically formed by the coalescence of several dendritic ulcers.
• indolent u. — see eosinophilic ulcer, refractory ulcer (below).
• infectious dermal u. — a systemic, fatal bacteremia of snakes manifested by multiple, small cutaneous ulcers. Called also scale rot.
• intestinal u. — is rare in all species. When they do occur, intestinal ulcers usually cause signs of chronic enteritis. It is a common lesion in adenocarcinoma of the intestine. See also peptic ulcer.
• lip u. — see eosinophilic ulcer.
• lip and leg u. — see ulcerative dermatosis.
• melting u. — see collagenase ulcer (above).
• u. mound — a gastric ulcer viewed tangentially radiographically creates a mound in the otherwise smooth outline of radiopaque material in the stomach.
• necrotic u. of swine — see ulcerative granuloma of swine.
• perforating u. — one that involves the entire thickness of an organ, creating an opening on both surfaces. See also ulcer perforation.
• phagedenic u. — a necrotizing lesion in which tissue destruction is prominent.
• refractory u. — a chronic, superficial corneal ulceration in dogs, particularly common in Boxers, that extends into the superficial stroma, often undermining epithelium at the edges. The cause is unknown but abnormalities of the basal epithelial cells and anterior stroma have been noted. Response to the usual methods of treatment for corneal ulceration is characteristically very slow; superficial keratectomy is the treatment of choice. Called also superficial corneal erosion syndrome, Boxer ulcer.
• rodent u. — see eosinophilic ulcer.
• stress u. — superficial ulcerations or erosions of mucosa in the stomach, duodenum or colon. The possible predisposing factors include changes in the microcirculation of the gastric mucosa, increased permeability of the gastric mucosa barrier to H+, and impaired cell proliferation.
• stromal u. — a corneal ulcer involving the stroma.
• trophic u. — one due to imperfect nutrition of the part. In dogs, may develop in digital and metatarsal pads in association with tibial nerve injury.

Endoscopic images of a duodenal ulcer.

An ulcer (from Latin ulcus) is an open sore of the skin, eyes or mucous membrane, often caused, but not exclusively, by an initial abrasion and generally maintained by an inflammation, an infection, and/or medical conditions which impede healing. In other words, it is a macroscopic discontinuity of the normal epithelium (microscopic discontinuity of epithelium is called erosion). Other causes of skin ulcerations include pressure from various sources and venous insufficiency.

Ulcers are healing wounds that develop on the skin, mucous membranes or eye. Although they have many causes, they are marked by:

1. Loss of integrity of the area
2. Secondary infection of the site by bacteria, fungus or virus
3. Generalized weakness of the patient
4. Delayed healing

Ulcer classification schemes

Example of a skin ulcer on the left leg

The skin is the largest organ of the human body. Classification systems are used to communicate the severity and depth of an ulcer. It is an easy way to communicate changes for the better, or worse.

Merck Manual classification

• Stage 1: *The skin is red. The underlying tissue is soft. The redness disappears with minor pressure.
• Stage 2: There is redness, swelling and hardening of the skin around the area. Sometimes there is blistering. Sometimes there is loss of the superficial skin.
• Stage 3: The skin becomes necrotic. There may be exposure of the fat beneath the skin. The skin may be lost through all its layers.
• Stage 4: There is more loss of fat and more necrosis of the skin through to the muscle beneath.
• Stage 5: Continuing loss of fat and necrosis of muscle below.
• Stage 6: Bone destruction begins with irritation of the bone, erosion of the bone cortex progressing to osteomyelitis. There may be sepsis of a joint, pathologic fracture or generalized body infection, septicemia.

This staging system for rating ulcers, is designed to rate the severity of pressure ulcers

• Stage 1 - There is erythema of intact skin which does not blanch with pressure. It may be the heralding lesion of skin ulceration.
• Stage 2 - There is partial skin loss involving the epidermis, dermis, or both. The ulcer is superficial and presents as an abrasion, blister, or wound with a shallow center.
• Stage 3 - This is an entire thickness skin loss. It may involve damage to or necrosis of subcutaneous tissue that may extend down to, but not through, the underlying fascia. The ulcer presents as a deep crater with or without undermining of adjacent intact tissues.
• Stage 4 - Here there is entire thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. Tendons, and joints may also be exposed or involved. There may be undermining and/or sinus tracts associated with ulcers at this stage.

Wagner's classification

This classification system is intended to rate the severity of diabetic foot ulcerations

• Grade 0 - Skin with prior healed ulcer scars, areas of pressure which are sometimes called pre-ulcerative lesion or the presence of bony deformity which puts pressure on an unguarded point.
• Grade 1-A - The wound is superficial in nature, with partial or full-thickness skin involvement but does not include tendon, capsule or bone.
• Grade 1-B - As above, the wound is superficial in nature, with partial or full thickness skin involvement but not including tendon, capsule nor bone; however the wound is infected. The definition of this wound implies superficial infection without involvement of underlying structures. If the wound shows signs of significant purulence or fluctuance, further exploration to expose a higher grade classification of infection is in order.
• Grade 1-C - As above but with vascular compromise.
• Grade 1-D - As above but with ischemia. Because ischemia is a type of vascular compromise, the distinction between these two grades is often difficult to make.
• Grade 2-A - Penetration through the subcutaneous tissue exposing tendon or ligament, but not bone.
• Grade 2-B - Penetration through the deep tissues including tendon or ligament and even joint capsule but not bone.
• Grade 2-C - As above 2B, but including ischemia
• Grade 2-D - As above 2C, but including infection
• Grade 3-A - A wound which probes to bone but shows no signs of local infection nor systemic infection.
• Grade 3-B - A wound which probes to bone and is infected.
• Grade 3-C - A wound which probes to bone is infected and is ischemic.
• Grade 3-D - A wound which probes to bone characterized by active infection, ischemic tissues and exposed bone.
• Grade 4 - Gangrene of the forefoot
• Grade 5 - Gangrene of the entire foot

University of Texas classification of diabetic ulcer

Classification on table system^[1]

Other locations

1. Inferior members: most ulcers of the foot and leg are caused by underlying vascular insufficiency. The skin breaks down or fails to heal because of repeated trauma. Pressure of the nail can cause subungual ulceration. These are most frequently seen in diabetics who have a very low potential to heal from injury.

1. Sacrum and ischium
2. Mouth ulcer
3. Peptic ulcers: This includes ulcers of the esophagus, stomach, large and small intestine
4. Genitalia: May be penile, vulvar or labial. Most often are due to sexually transmitted diseases
5. Eyes: corneal ulcers are the most common type. Conjunctival ulcers also occur.

Pathology of ulceration

Causes

The most common causes (not in order) are:

• Bacterial infection
• Viral infection
• Fungal infection
• Cancer - both 'primary' and 'secondary'
• Venous stasis
• Arterial Insufficiency
• Diabetes
• Rheumatoid Arthritis
• Amyloidosis
• Loss of mobility
• Hypertension
• Gastroesophageal reflux disease

Types

Some specific types of ulcers are:

• Peptic ulcer (of the stomach, esophageal cardium or duodenum)
• Mouth ulcer
• Pressure ulcer (decubitus)
• Crural ulcer (due to venous insufficiency or other causes)
• Hunner's ulcer (of the bladder caused by Interstitial Cystitis)
• Ulcerative colitis (of the colon)
• Curling's ulcer
• Cushing ulcer
• Arterial insufficiency ulcer
• Venous insufficiency ulcer
• Diabetic foot ulcer
• Corneal ulcer

References

This entry is from Wikipedia, the leading user-contributed encyclopedia. It may not have been reviewed by professional editors (see full disclaimer)

Dansk (Danish)
n. - (gastric ulcer) mavesår, åbent sår

Nederlands (Dutch)
zweer

Français (French)
n. - ulcère

Deutsch (German)
n. - Geschwür

Ελληνική (Greek)
n. - (παθολ.) έλκος, εξέλκωμα, πληγή, (μτφ.) πηγή μόνιμης ταλαιπωρίας, πληγή

Italiano (Italian)
ulcera

Português (Portuguese)
n. - úlcera (f)

Русский (Russian)
язва (желудка)

Español (Spanish)
n. - úlcera, llaga

Svenska (Swedish)
n. - sår, sårnad, rötsår, skamfläck

中文（简体） (Chinese (Simplified))
溃疡, 腐烂物

中文（繁體） (Chinese (Traditional))
n. - 潰瘍, 腐爛物

한국어 (Korean)
n. - 궤양, 병폐

日本語 (Japanese)
n. - 潰瘍, 病幣, 病根

العربيه (Arabic)
‏(الاسم) قرحه‏

עברית (Hebrew)
n. - ‮כיב-קיבה, אולקוס, פצע, שחיתות‬

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