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 assessment of participants’ income status, most were in the lower sector. The result indicated that the major
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characteristic of PUD patients in North Eastern Nigeria is low wealth. The age range of my respondents was 10 to 50 years with an average age of 32 years and a standard deviation of 10.67. Gender was also found to be a characteristic of PUD patients because females had more PUD than males.
The results from this research clearly demonstrate that gender and income status are major characteristics of PUD. Cigarette smoking and alcohol drinking may be among the characteristics of PUD patients in northern Nigeria. The void in the literature on PUD indicates that sponsored research is vital by International Nongovernmental agencies and governments in Africa.
Key words: peptic ulcer disease, epidemiology, prevalence, diagnosed patients, wealth, alcohol consumption, cigarette smoking, Nigeria, Africa
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TABLE OF CONTENTS
TITLE PAGE…………………………………………………………………………………………………i
CERTIFICATION PAGE …………………………………………………………………………… ii
APPROVAL PAGE ……………………………………………………………………………………. iii
DEDICATION …………………………………………………………………………………………….. iv
ACKNOWLEDGEMENTS …………………………………………………………………………… v
ABSTRACT ……………………………………………………………………………………………….. vii
TABLE OF CONTENTS ……………………………………………………………………………… ix
LIST OF TABLES ……………………………………………………………………………………… xii
LIST OF FIGURES …………………………………………………………………………………… xiii
LIST OF ABBREVIATIONS …………………………………………………………………….. xiv
CHAPTER 1 ………………………………………………………………………………………………… 1
1.0 INTRODUCTION …………………………………………………………………………………… 1
1.1 Overview of Peptic Ulcer ……………………………………………………………………… 1
1.2 Aetiology of Peptic Ulcer………………………………………………………………………. 2
1.3 Signs and Symptoms of Peptic Ulcer Disease…………………………………………. 4
1.4 Factors that Influence Development of Peptic Ulcer ……………………………… 5
1.5 Lifestyle Practices and Peptic Ulcer Disease ………………………………………….. 8
1.6 Aims: …………………………………………………………………………………………………. 11
1.7 Research Question: …………………………………………………………………………….. 12
1.8 Null Hypothesis (H0): …………………………………………………………………………. 12
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1.9 Hypothesis (H1): …………………………………………………………………………………. 12
1.91 Objectives ………………………………………………………………………………………… 12
CHAPTER 2 ………………………………………………………………………………………………. 13
2.0 MATERIALS AND METHODS ……………………………………………………………. 13
2.1 The Study Area ……………………………………………………………………………………… 13
2.2 Data Collection and Analysis ………………………………………………………………. 17
CHAPTER 3 ………………………………………………………………………………………………. 20
3.0 RESULTS AND ANALYSIS ………………………………………………………………….. 20
3.1 Demographic Information ………………………………………………………………….. 20
3.2 Wealth ……………………………………………………………………………………………….. 22
3.3 Environmental Factors ………………………………………………………………………. 24
3.4 Lifestyles ……………………………………………………………………………………………. 25
CHAPTER 4 ………………………………………………………………………………………………. 28
4.0 DISCUSSION ……………………………………………………………………………………….. 28
4.1 Limitations of Study …………………………………………………………………………… 35
4.2 Challenges …………………………………………………………………………………………. 35
4.3 Recommendations ……………………………………………………………………………… 36
CHAPTER 5 ………………………………………………………………………………………………. 38
5.0 CONCLUSION ……………………………………………………………………………………… 38
APPENDIX I ……………………………………………………………………………………………… 39
Anatomy of the Stomach ………………………………………………………………………….. 39
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APPENDIX II …………………………………………………………………………………………….. 41
Diagnosis of Peptic Ulcer …………………………………………………………………………. 41
APPENDIX III …………………………………………………………………………………………… 42
Human Subject Online Training Certificate …………………………………………….. 42
APPENDIX IV ……………………………………………………………………………………………. 43
APPENDIX V …………………………………………………………………………………………….. 44
REFERENCES …………………………………………………………………………………………… 49
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LIST OF TABLES
Table 1: Showing the income groups of the respondents
Table 2: Showing the income levels and gender of the PUD patients at FMC
Table 3: Showing the socioeconomic status PUD patients respondents
Table 4: Showing the different sources of drinking water for respondents
Table 5: Showing the number and percentage of the respondents that smoke cigarettes and don’t smoke cigarettes
Table 6: Showing the frequency of smoking among the PUD patients
Table 7: Showing the number and percentage of the respondents that drink alcohol and do not drink alcohol
Table 8. Showing the frequency of alcohol intake among the PUD patients that drink alcohol
Table 9: Comparing the various characteristics of PUD patients with five studies from different countries
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LIST OF FIGURES
Figure 1: Showing the peptic ulcer disease
Figure 2: Showing the defensive and aggressive factors peptic ulcer disease
Figure 3: Showing the development of peptic ulcer disease
Figure 4: Showing map of Adamawa State showing local governments and ethnic groups
Figure 5: Showing the proximity of Federal Medical Center from the American University of Nigeria
Figure 6: Showing arial view of the Federal Medical Center, Yola
Figure 7: Showing all the local governments in which the respondents live
Figure 8: Showing the income groups of the respondents
Figure 9: Showing the toilet facilities of the respondents
Figure 10: Comparing my result on cigarette smoking with other studies around the world.
Figure 11: Comparing my result on alcohol consumption with other studies around the world.
Figure 12: Comparing my result on gender with other studies around the world.
Figure 13: Comparing my result on wealth other studies around the world.
Figure 14: Anatomy of the stomach
Figure 15: The Anatomy of the stomach and duodenum
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LIST OF ABBREVIATIONS
FMC –Federal Medical Center
PUD – Peptic Ulcer Disease
OH – Hydroxyl
O2- – Oxide ion
H2O2 – Hydrogen peroxide
NSAIDs – Nonsteroidal anti-inflammatory drugs
NGOs – Nongovernmental Organizations
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CHAPTER 1
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 non-filtered 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 non-secretors, 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 co-factor 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.
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