Populations and Risk Factors
- H. pylori infection (present in 60-80% of gastric ulcers, 90-95% of duodenal ulcers)
- Chronic NSAID use — aspirin, ibuprofen, naproxen (second most common cause; highly relevant to MT clients)
- Smoking (impairs mucosal healing and increases acid secretion)
- Heavy alcohol consumption
- Physiologic stress: critical illness, severe burns (Curling ulcers), head trauma (Cushing ulcers)
- Family history
- Age: duodenal ulcers peak at ages 30-50. Gastric ulcers peak at ages 50-70
- Zollinger-Ellison syndrome (gastrinoma causing massive acid hypersecretion — rare)
- Concurrent corticosteroid and NSAID use (synergistic ulcer risk)
Causes and Pathophysiology
- H. pylori mechanism: The bacterium colonizes the gastric mucosa beneath the mucus layer, produces urease (neutralizing local acid to create a survivable microenvironment), and triggers chronic inflammation. The inflammatory cascade disrupts the mucous barrier and stimulates acid secretion, leading to mucosal erosion and ulcer crater formation.
- NSAID mechanism: NSAIDs inhibit cyclooxygenase-1 (COX-1), reducing prostaglandin synthesis. Prostaglandins maintain mucosal blood flow, stimulate mucus and bicarbonate secretion, and promote epithelial regeneration. Without this protection, acid and pepsin digest the unprotected mucosa.
- Gastric vs. duodenal ulcers:
- Gastric ulcers: pain worsens with eating (acid stimulation); weight loss is common; often associated with older age
- Duodenal ulcers: pain improves with eating (food buffers acid in the duodenum); worse 2-3 hours after meals and at night; weight gain is possible (eating relieves pain)
- Complications: Upper GI hemorrhage (melena, hematemesis — most common complication), perforation (peritonitis — surgical emergency), gastric outlet obstruction (from edema or scarring), penetration into adjacent organs (pancreas, liver)
Signs and Symptoms
- Burning, gnawing epigastric pain — the hallmark symptom
- Duodenal: pain relieved by food and antacids. Worse on empty stomach and at night
- Gastric: pain worsened by food. Nausea, early satiety, anorexia
- Bloating, belching, nausea
- Weight loss (gastric ulcer) or weight gain (duodenal — eating relieves pain)
- Hematemesis (vomiting blood — bright red or coffee-ground) — upper GI hemorrhage
- Melena (black, tarry stools) — digested blood from upper GI source
- Sudden severe abdominal pain with board-like rigidity — suggests perforation (surgical emergency)
Red Flags
- Hematemesis or melena: Upper GI hemorrhage — emergency referral; call 911 if severe
- Sudden severe abdominal pain with board-like rigidity: Perforation with peritonitis — surgical emergency; call 911
- Signs of shock (tachycardia, pallor, hypotension, diaphoresis) during a session — hemorrhage or perforation. Activate emergency services
- Persistent vomiting or inability to eat: May indicate gastric outlet obstruction — urgent medical referral
MT Considerations
- Relaxation massage is beneficial: Stress reduction supports mucosal healing by reducing acid secretion via parasympathetic activation. Massage can address secondary musculoskeletal tension from chronic pain guarding (thoracolumbar paraspinals, abdominal wall guarding).
- Deep abdominal massage: Contraindicated over the epigastric region during active ulcer disease
- Positioning: Prone positioning may be uncomfortable (pressure on epigastrium). Side-lying or semi-reclined preferred during active symptoms
- Session timing: For duodenal ulcer clients, suggest eating lightly before sessions (empty stomach increases pain). For gastric ulcer clients, time sessions away from meals.
- NSAID counseling: Clients who self-medicate with NSAIDs for musculoskeletal pain are at elevated ulcer risk. Encourage discussion with their physician about gastroprotection (PPI co-prescription) if chronic NSAID use is ongoing.
- Emergency recognition: If a client develops hematemesis, melena, or acute severe abdominal pain during a session, cease treatment immediately and activate emergency services
CMTO Exam Relevance
- Category: A7 Systemic Conditions — Digestive
- Differentiate gastric from duodenal ulcers by meal-related pain pattern (gastric: worse with food; duodenal: relieved by food)
- Epigastric pain must be differentiated from musculoskeletal complaints
- Hematemesis and melena as emergency red flags
- NSAID use is extremely common among MT clients — gastric protection awareness
- Perforation with peritonitis is a surgical emergency — board-like abdominal rigidity
- H. pylori eradication therapy (triple therapy: PPI + 2 antibiotics)
Key Takeaways
- PUD is most commonly caused by H. pylori infection and chronic NSAID use
- Burning epigastric pain is the hallmark — meal-related timing differentiates gastric from duodenal ulcers
- Deep abdominal massage is contraindicated over active ulcer sites
- Hematemesis and melena are emergency red flags indicating GI hemorrhage
- Relaxation massage supports healing by reducing stress-mediated acid secretion
- NSAID use among MT clients creates direct relevance — encourage gastroprotection discussion with physician