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PEPTIC ULCER DISEASE
Peptic ulcer disease is the presence of ulceration in the stomach and proximal duodenum commonly and in the lower esophagus, distal duodenum or jejunum infrequently. It is characterized by mucosal damage secondary to pepsin and gastric acid secretion.
It is the principal cause of upper gastrointestinal hemorrhage.
Appropriate therapy depends on the cause of peptic ulcer disease.

Introduction

  • Peptic ulcer disease (PUD) is characterized by mucosal damage secondary to pepsin and gastric acid secretion
  • It is the principal cause of upper gastrointestinal (UGI) hemorrhage
  • Most commonly occurs in the stomach and proximal duodenum; infrequently, in the lower esophagus, distal duodenum or jejunum
  • Giant ulcer with size of 3 cm is an atypical type of PUD that is now rarely encountered
  • Dyspepsia is a nonspecific term indicating discomfort in the upper abdomen
  • Refractory PUD is considered in patents with ulcer that failed to heal after 8-12 weeks of therapy

Signs and Symptoms

Clinical Features
  • Epigastric pain is the most common symptom of PUD but occurs only in minority of patients
    • Pain of duodenal ulcer usually occurs 2-3 hours after a meal, improves with food or antacid, and sometimes awakens patient at night
    • Pain of gastric ulcer is more commonly worsened by food intake and occurs shortly after meals
      • May be associated with weight loss due to fear of food intake
  • Other symptoms include indigestion, vomiting, loss of appetite, inability to tolerate fatty foods, heartburn
    • Nausea and vomiting are commonly experienced by patients with prepyloric or pyloric channel ulcers

Alarm Symptoms

  • Hematemesis, melena, or anemia may suggest bleeding
  • Vomiting and early satiety may be due to obstruction
  • Anorexia or weight loss may suggest cancer
  • Upper abdominal pain radiating to the back that persists may be due to penetration
  • Spreading upper abdominal pain that is severe may suggest perforation

Risk Factors

Risk Factors
  • In 70% of cases, 25- to 64-year old patients are affected
  • 48% and 50% of cases are secondary to Helicobacter pylori infection and nonsteroidal anti-inflammatory drugs (NSAIDs) respectively
    • Some evidence states that H pylori infection may be food or water borne and may spread from person to person
    • In patients with a bleeding ulcer, it is recommended to test for and treat H pylori
    • NSAIDs inhibit the formation of prostaglandins and their protective effect on the gastric mucosa (ie stimulates mucus and bicarbonate secretion, epithelial cell proliferation, and increase of mucosal blood flow)
      • Patients who are on long-term NSAIDs have an annual risk of life-threatening ulcer-related complication of 1-4%
    • H pylori plus NSAID use increases the risk and intensity of NSAID-related mucosal damage
  • Other causes may include use of steroids, bisphosphonates, potassium chloride or chemotherapeutic agents, presence of acid-hypersecretory states (eg Zollinger-Ellison syndrome), cancer or stress [eg multiorgan failure, ventilator support, extensive burns (Curling’s ulcer) or head injury (Cushing’s ulcer)], lifestyle factors, genetic factors
  • In patients with NSAID-related GI complications, additional contributing factors include history of complicated GI event, age, concomitant use of anticoagulants, corticosteroids, other NSAIDs including low-dose Aspirin, high-dose therapy, chronic debilitating disorders
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