Peptic ulcer disease
Peptic ulcer disease is a mucosal break in the stomach or duodenum caused chiefly by Helicobacter pylori infection or NSAID use, diagnosed by upper endoscopy with biopsy of gastric ulcers to exclude malignancy. Treatment eradicates H. pylori when present, stops the ulcerogenic drug, and heals the ulcer with a proton pump inhibitor, while its complications of bleeding, perforation, and obstruction drive most of its morbidity.
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What this article covers
- Overview
Definition: peptic ulcer disease (PUD) is a break in the mucosa of the stomach or duodenum through the muscularis mucosae, produced when acid and pepsin overwhelm mucosal defense.
- Epidemiology
H. pylori prevalence differs by site: present in roughly 90% of duodenal ulcers and roughly 70% of gastric ulcers; NSAIDs skew toward gastric ulcers, but H.
- Risk factors
Helicobacter pylori infection: the leading identifiable risk factor, colonizing the gastric mucosa for life if untreated.
- Pathophysiology
Loss of mucosal defense versus acid load: ulceration develops when protective mechanisms (mucus and bicarbonate secretion, mucosal blood flow, prostaglandin-mediated repair) are overwhelmed by acid and pepsin.
- Clinical features
Epigastric pain, the most frequently reported symptom: gnawing or burning, worse with fasting, relieved by food, antacids, or antisecretory therapy.
- Differential diagnosis
Gastroesophageal reflux disease: heartburn and regurgitation, worse supine or postprandial, no demonstrable mucosal break (gastroesophageal reflux disease).
- Diagnosis
Upper endoscopy establishes the diagnosis: direct visualization of the mucosal defect is the most accurate and most common way PUD is confirmed; every gastric ulcer requires biopsy of the margins to…
- Management
Remove the cause first: after endoscopic confirmation of uncomplicated PUD, discontinue any ulcerogenic drug (chiefly NSAIDs and aspirin not needed for a compelling indication).
- Complications
Bleeding: the most common complication, as overt hematemesis, melena, or hematochezia, or obscure bleeding with iron deficiency anemia.
- Prognosis
Excellent with source control: successful H.
- Prevention
Test-and-treat H. pylori before it causes disease: patients starting long-term low-dose aspirin or NSAID therapy, or with unexplained iron deficiency anemia or idiopathic thrombocytopenic purpura, should be tested and treated if positive.
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- Gastric cancer
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- Gastroesophageal reflux disease (GERD)
GERD is retrograde reflux of gastric contents into the esophagus causing heartburn and regurgitation, diagnosed clinically and confirmed by response to an empiric PPI trial, with endoscopy reserved for alarm features or refractory symptoms. Management proceeds from lifestyle measures through an 8-week once-daily PPI trial, dose escalation or agent switch for partial response, and fundoplication for medication-refractory or regurgitation-predominant disease.
- Mallory-Weiss syndrome
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- Nonsteroidal anti-inflammatory drugs
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- Dyspepsia
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