Abstract
Peptic ulcer disease is a disorder in the gastrointestinal tract. It is caused by an increase
in stomach acid. There are only a few studies on peptic ulcer disease in Africa. This
study was conducted to characterize the lifestyle, wealth, and environmental factors of
peptic ulcer patients in the Northeastern Nigeria. The lifestyle factors that were
examined were cigarette smoking and alcohol consumption. A targeted sampling
method was used to sample 52 PUD (n=52) patients at Federal Medical Center, Yola.
I used mixed methods (quantitative and qualitative techniques) approaches for data
collection. Structured questionnaires were administered to PUD patients, and
questions on the lifestyle, wealth, and environmental factors of typical PUD patients
were asked.
The result showed that cigarette smoking and alcohol consumption are not
characteristics of typical PUD patients. More than 70% of the subjects stated they
neither smoked cigarettes nor drank alcohol. Based on the asses
1.0 INTRODUCTION
1.1 Overview of Peptic Ulcer
Peptic ulcer disease (PUD) is a gastrointestinal disorder that occurs as a result of
developing a hole or sore within the lining of stomach, or duodenum, which forms the
first part of the ileum (small intestine) (Lin et al., 2015). This is caused by high increase
in the gastric acid found in the stomach. PUD poses a serious medical problem to
humans, and it affects millions of people in their everyday lives. It increases the
morbidity and mortality rates throughout the world’s population (Siddique, 2014). For
example, approximately 4 million people have peptic ulcer disease in the United
States, and about 350,000 new cases of PUD are diagnosed each year (Siddique, 2014).
Peptic ulcer disease has been identified as the most common disorder of the
gastrointestinal tract.
The incidence of this disease is constantly increasing in developing countries, while it
has decreased in developed countries (Al-Zubeer et al., 2012). PUD has continued to
be a serious socio-medical challenge in the world (Konturek et al., 2003). The reasons
behind the decrease of peptic ulcer incidence in developed countries have been
attributed to the early detection and treatment of the disease (Al-Zubeer et al., 2012).
Other factors that have led to the decline in the PUD in developed countries include
increase in hygiene and sanitation in the food services sector; as well as increase in
health awareness in developed countries. However, the reasons for the increase in PUD
among developing countries are not yet clear. PUD poses life-threatening problems,
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such as ulcer perforations and bleeding in the gastrointestinal tracts (Konturek et al.,
2003).
In the last decades of the 20th Century, the morbidity and mortality rates of peptic ulcer
disease were very high worldwide, but remarkable developments in the field of
epidemiology reduced the prevalence and the incidence of peptic ulcer in the world’s
population (Malfertheiner, Chan, & McColl, 2009). These epidemiological
developments, including tracking of diseases and outbreaks, are used to determine the
mode of transmission of diseases. The development in epidemiology also determines
whether a disease is zoonotic, chronic, or pathogenic (Malfertheiner et al., 2009). The
epidemiological development further involves the identification of health indicators,
determinants of diseases, and demographic information, which are quantifiable
evidence used by epidemiologists and other health researchers in describing the health
situation of a particular population (World Health Organization, 2000).
1.2 Aetiology of Peptic Ulcer
Peptic Ulcer Disease (PUD) is among the major gastrointestinal tract disorders and is
partially caused by the increase in secretion of gastric acid. It occurs in the stomach
and duodenum (for the anatomy of both structures, see Appendices I & II). The other
contributing factors of peptic ulcer development include cigarette smoking (Ali, Ullah,
Akhtar, Ali Shah, & Junaid, 2013; Andersen, Jørgensen, Bonnevie, Grønbæk, &
Sørensen, 2000a; Maity, Biswas, Roy, Banerjee, & Bandyopadhyay, 2003), use of
analgesics, stress (Levenstein, 1998), social conditions (Al-Zubeer et al., 2012),
Helicobacter pylori, inheritance (blood group), personal traits, diet, and psychological
factors (Johnsen, Førde, Straume, & Burhol, 1994).
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Peptic ulcer mainly occurs in the proximal duodenum (duodenal ulcer) or stomach
(gastric ulcer) (Fig. 1). PUD forms a strong defensive mechanism against the
gastrointestinal mucosa, such that bicarbonate and mucus secretion are overpowered
by the detrimental effects of pepsin and gastric acid (Sung, Kuipers, & El-Serag,
2009). The study by Al-Zubeer et al. reveals that the cause of peptic ulcer can be
attributed to stomach cells that secrete digestive juices (acid), which cause corrosion
and huge damage in the lining of esophagus, duodenum, or stomach (Al-Zubeer et al.,
2012).
Fig.1 Source: Medicine Net, Inc.
Peptic ulcer disease also occurs due to disorder in the balance between hostile factors
such as nonsteroidal anti-inflammatory drugs (NSAIDs), gastric acid, pepsin, and
Helicobacter pylori, and protective factors such as bicarbonate, prostaglandins, blood
flow to the mucosa, and mucus in the stomach and duodenum (Lin et al., 2015). It is
characterized by high intensity of pain in the right hypochondrium (upper part of the
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abdomen) during food intake. Epigastric pain is also a characteristic of peptic ulcer
(Ali et al., 2013).
Loss of balance between some defensive and aggressive (gastroprotective) factors also
leads to the development of peptic ulcer (Fig. 2). The factors that are considered to be
aggressive factors can be either exogenous or endogenous in nature, and they both
cause imbalance between defensive and aggressive in the stomach, thereby causing
PUD. Endogenous factors include leukotrienes, pepsin, hydrochloric acid, and
refluxed bile, intermediates of reactive oxygen such as OH, O2-, and H2O2. The
exogenous factors that cause peptic ulcer include chronic alcohol consumption,
Helicobacter pylori infection, smoking, alcohol consumption, and intake of
nonsteroidal anti-inflammatory drugs (NSAIDs) (Maity et al., 2003).
Fig. 2. A, Defensive factors; B, aggressive factors. Source: gi.jhsps.org
1.3 Signs and Symptoms of Peptic Ulcer Disease
The signs and symptoms of peptic ulcer include tenderness in the epigastric area,
gnawing pain, and burning discomfort. PUD may be asymptomatic in some individuals
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while the symptoms can show with heavy complications in some patients. PUD
patients may show different symptoms such as bleeding, serious perforations in the
intestinal lining, mild abdominal discomfort, hematemesis (vomiting blood), weight
loss, heart burn, and itching between umbilicus and xiphoid (Ali et al., 2013;
Malfertheiner et al., 2009). Other symptoms include abdominal pain, vomiting, and
nausea. Infected people may experience pain in the epigastrium and the pain is usually
not radiated to other parts of the body. The pain begins to radiate to the back when
peptic ulcer penetrates posteriorly and may also occur in the origin of the pancreas
(Malfertheiner et al., 2009). Peptic ulcer causes a serious and dangerous breaking in
the duodenal and gastric mucosa. Duodenal and gastric ulcers are related to the
corrosive action of hydrochloric acid and pepsin along the upper gastrointestinal tract.
Three millimeters is the range of most ulcers and a number of centimeters in diameter
(Malfertheiner et al., 2009).
1.4 Factors that Influence Development of Peptic Ulcer
In the 1980’s, excessive eating, alcohol consumption, rich food with spices, eating
much of fatty foods, and stress were identified as major factors leading to peptic ulcer
development (Levenstein, 1998). Later, other factors that are responsible for peptic
ulcer disease were discovered to be Helicobacter pylori, smoking, co-administration
of corticosteroids, NSAIDs, heredity, co-administration of warfarin, and other
uncommon factors such as tuberculosis and Crohn’s disease, which may be idiopathic
at times (Ali et al., 2013). Socioeconomic status is also a contributing factor to the
development of peptic ulcer because individuals with low economic status are mostly
exposed to H. pylori infection, and this leads to development of PUD (Mhaskar et al.,
2013).
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However, the major factor that causes peptic ulcer disease has been identified to be
Helicobacter pylori, which is found in the intestinal walls of humans. H. pylori is a
flagellated, spiral-shaped bacilli and a Gram-negative bacterium that is found mostly
in the epithelial lining of the stomach and in the gastric mucous layer (Salih, 2009).
H. pylori can be detected through the clinical analysis of stool from the infected
individuals by monoclonal antigen detection (Mhaskar et al., 2013).
The prevalence of H. pylori has been revealed by a wide range of studies around the
world. Residential overcrowdings, use of pit toilet/latrines, and low wealth are heavily
linked with the prevalence of H. pylori infection (Goodman & Cockburn, 2001).
Further, migrations between rural and urban settlements, and low wealth are other
important factors that contributes to H. pylori infections (Mbengue et al., 1997). The
possible risk factors of H. pylori infections are drinking of non-boiled water or nonfiltered water, fish consumption, eating of restaurant food, low socioeconomic status,
meat consumption, and smoking. This is because H. pylori, which is also a causative
pathogen for PUD, can easily be transmitted through drinking water, meat
consumption, and meals that are prepared in a dirty environment.
Approximately 50 percent of the world population is infected with H. pylori, and this
is more than 3 billion people worldwide. People in developing countries are mostly
affected by this bacterium. Because of H. pylori infection, a high number of people
around the world develop peptic ulcer disease during their lifetimes and the majority
of these people that are infected with peptic ulcer disease might develop gastric cancer
in their lifetime (Salih, 2009). H. pylori is responsible for over 80% of gastric ulcers
and about 90% of duodenal ulcers. This bacterium is very common and it affects over
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two-thirds of the total world population (Center for Disease Control and Prevention,
1998). Children are less affected by H. pylori infection in developing countries, but
more than 60% the population of older people are most affected (Salih, 2009). H.
pylori causes peptic ulcer by breaking down of the mucosa found on the lining of the
gastrointestinal tract (Fig. 3). This creates room for the digestive acids in the digestive
tracts to affect the wall of the intestine and stomach (Al-Zubeer et al., 2012b).
Fig. 3 Development of peptic ulcer disease. Source: gi.jhsps.org
In addition, genetic factors are highly linked with the development of peptic ulcer
disease, which might have strong clinical and public health implications (Suadicani,
Hein, & Gyntelberg, 1999). These factors contribute to the lifetime prevalence of
peptic ulcer disease among the people with non-secretors of ABH antigen and Lewis
phenotype Le(a+b-). PUD is also prevalent in individuals with O and A phenotypes
among the blood groups ABO. Lewis blood group phenotype Le(a+b-) or nonsecretors, blood groups A and O are highly attributed with the PUD (Hein, Suadicani,
& Gyntelberg, 1997; Suadicani et al., 1999).
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1.5 Lifestyle Practices and Peptic Ulcer Disease
Various lifestyle practices contribute to the development of peptic ulcer. Cigarette
smoking is a factor that influences the development of peptic ulcer. It heavily
contributes to the complications, incidence, reoccurrences, and mortality, and causes
serious delays in the healing process of peptic ulcer disease. Cigarette smoking is a cofactor to H. pylori, and they both create room for the development of peptic ulcer
disease (Andersen et al., 2000). The rate of peptic ulcer disease in people who smoke
is twice that of people who do not smoke, and cigarette smoking has a dose-dependent
effect on the development and incidence of peptic ulcer disease (Ma, Chow, & Cho,
1998).
Peptic ulcer disease is highly associated with the inhalation of cigarette smoke by the
smokers and non-smokers. This increases the rate of development of peptic ulcer
disease in people with the longer years of smoking. Both light and heavy smokers are
at greater risk of developing peptic ulcer than non-smokers, and the risk of developing
PUD increases as the number of smoking pack-years increases. It has been understood
that one of the major causes of peptic ulcer is correlated to cigarette smoking more
than to other behavioral attitudes (Ma et al., 1998). Cigarette smoking promotes the
susceptibility of defensive factors and reduces the gastric mucosal protective factors
and also creates room for H. pylori infection. Nicotine and smoking increase the
stimulation of basal acid output that delays the healing process of peptic ulcer, and this
is more evident in cigarette smokers suffering from peptic ulcer disease. They have the
tendency to cause increase in the secretion of the gastric acid that is facilitated when
the H2-receptors are stimulated by histamine that is released after mast sell
degranulation (Maity et al., 2003).
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Alcohol intake is another risk factor for peptic ulcer disease. It facilitates development
of peptic ulcer and causes delay in healing of ulcer perforation in peptic ulcer patients.
Dangerous effects of alcohol on peptic ulcer is highly dependent on the dose intake.
High consumption of alcoholic drinks has negative effects in the management of
peptic ulcer as well as its development (Andersen et al., 2000). It increases the
concentration of the basal acid, thereby enabling H. pylori to attack the stomach and
duodenal walls. Consumption of over fourteen bottles of alcoholic drinks in a week
increases the risk of developing peptic ulcer (Andersen, Jørgensen, Bonnevie,
Grønbæk, & Sørensen, 2000).
According to Levenstein (1998), physiological stress contributes to the development
of peptic ulcers and it delays the healing process of the disease. Physiological distress
is highly connected with the output of gastric acid in patients with peptic ulcer disease.
The quantity of acid that get to the duodenum during stressful period might cause a
large escalation in the amount of gastric acid. This is a result of missing of meals or a
result of change in gastric motility. Individuals that are under stress are likely to sleep
less, drink alcohol, and/or smoke cigarettes, and these are risk factors that contribute
to the development of peptic ulcer (Levenstein, 1998). The evolution of Helicobacter
pylori infection could be facilitated into ulcer by stress through the production of
gastric hyperchlorhydria (when the gastric acid in the stomach is higher than the
reference range). Through the psychoneuroimmunological (interaction between
immune systems, nervous system and psychological processes in the human body)
mechanism, the equilibrium balance between Helicobacter pylori can be disrupted by
stress. Cigarette smoking is one of the behavioral mediators which create room for
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stress to reduce mucosal defensive mechanisms and allow H. plori to invade the
intestine (Levenstein, 1998).
Finally, wealth of individuals contributes to the risk of developing peptic ulcer.
Individuals with lower income status can easily be infected with H. pylori . Further,
lower income class and use of pit toilets are correlated with H. pylori infection because
low income earners live mainly in crowded environments and are prone to different
types of infection (Mbengue et al., 1997). It has been suspected that the H. pylori
infection is highly linked with drinking of impure water, food, and through oral
contact, and individuals with low wealth status are highly affected with the infection.
Most individuals with low income earners have no access to clean water and they live
mostly in dirty and crowded environments. Wealth has a very important role to play
in peptic ulcer development as it creates room for H. pylori infections. It has a very
strong association with peptic ulcer disease (Levenstein & Kaplan, 1998).
In this study, I characterized the lifestyle, wealth, and environmental factors (source
of drinking water and toilet facilities) of typical PUD patients in Yola, northeastern
Nigeria. The study of these characteristics is very important in the field of public
health, to determine the epidemiology, management, and prevention of peptic ulcer
disease. Furthermore, this research project tends to explore and provide an in-depth
understanding of the possible lifestyle (cigarette smoking and alcohol consumption)
and socioeconomic factors that define typical PUD patients.
Moreover, there are quite a low number of publications on this topic from Nigeria and
Africa, which shows that characteristics of typical peptic ulcer patients have not been
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thoroughly identified and studied in Nigeria and Africa. Based on all the literature
reviewed, the effects of alcohol consumption, cigarette smoking, and socioeconomic
status on peptic ulcer development has not been well studied in Nigeria, as well as in
Africa. Most of the works on peptic ulcer disease were done by the Western countries
and that is why the study of the characteristics of lifestyle and socioeconomic factors
that influence the development of peptic ulcer disease is very important.
The characteristics of typical PUD patients were examined between alcohol
consumption, cigarette smoking, and socioeconomic status in the development of PUD
in diagnosed patients at FMC. The low intake of alcoholic drinks, cigarette smoking,
and low exposure to stress was predicted to lower the rate of development of peptic
ulcer disease. Even though the study did not focus on physiological causes of peptic
ulcer, the work is very crucial in reducing the incidence and prevalence of peptic ulcer
disease in Nigeria. This is because the identification of the characteristics and risk
factors of PUD patients is a strong tool to stopping PUD infections. The work ended
with some suggestions on how to avoid risk factors of peptic ulcer that are associated
with lifestyle practices and the importance of visiting a hospital during illnesses.
1.6 Aims:
1. To characterize peptic ulcer patients by demographics, lifestyle, wealth, and
environmental factors in Yola, northeastern Nigeria.
2. To explore how lifestyle, wealth, and environmental factors compare to those
recorded for peptic ulcer patients in other parts of the world.
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1.7 Research Question:
What lifestyle behaviors, wealth, and environmental factors characterize
peptic ulcer patients in northeastern Nigeria?
1.8 Null Hypothesis (H0):
Lifestyle, wealth, and environmental factors do not help characterize peptic
ulcer patients in Yola, northeastern Nigeria.
1.9 Hypothesis (H1):
Lifestyle, wealth, and environmental factors help characterize peptic ulcer
patients in Yola, northeastern Nigeria.
1.91 Objectives
? To determine the number of patients who smoke cigarettes and how
much they smoke.
? To determine the number of patients who consume alcohol and how
much they consume.
? To determine monthly income of patients.
? To identify environmental factors that may affect patients.
? To collect data on patients with peptic ulcer disease in other parts of the
world