Peptic Ulcer Disease

Peptic ulcer disease (PUD) is the presence of one or more ulcerative lesions in the stomach or duodenum.
Etiologies include infection with Helicobacter pylori (most common), prolonged NSAID use (possibly in
combination with glucocorticoids), conditions associated with an overproduction of stomach acid
(hypersecretory states), and stress.
Definitions
• Peptic ulcer: a defect in the gastric or duodenal mucosa with a diameter of > 0.5 cm (>5mm) and a
depth that reaches the muscularis mucosae
• Gastric ulcer: a peptic ulcer of the gastric mucosa, typically located along the lesser curvature in the
transitional portion between the corpus and antrum
• Duodenal ulcer: a peptic ulcer of the duodenal mucosa, usually located on the anterior or posterior
wall of the duodenal bulb
Ulcers involve damage to
Erosions are more
Etiology the gastric mucosa
superficial than ulcers
Common causes of PUD extending beyond the
limited to the mucosa
The two major contributing muscularis mucosa layer
factors to the development of PUD are into the submucosa.
gastrointestinal infection with H. pylori and nonsteroidal anti-inflammatory drug (NSAID) use.
• Helicobacter pylori infection
◦ Associated with 40–70% of duodenal ulcers and 25–50% of gastric ulcers
◦ The rate of H. pylori infection (and, therefore, the development of PUD) is decreasing.
• Chronic NSAID use
◦ Associated with a fourfold risk of developing PUD
◦ Increases the risk for complications of PUD
Associated risk factors

• Shared risk factors for PUD, GERD and gastritis

(i.e., smoking, heavy alcohol use,
glucocorticoids, caffeine)
• Diet
• Psychological factors (e.g., anxiety, stress, PTSD)
• Genetic factors

Pathophysiology

• Imbalance between gastric mucosal protective and

destructive factors.
• There is usually a defect in the mucosa that extends to the
muscularis mucosa.
• Once the protective superficial mucosal layer is damaged,
the inner layers are susceptible to acidity.
• Further, the ability of the mucosal cells to secrete
bicarbonate is compromised.
• H. pylori colonizes gastric mucosa and causes inflammation.
• H. pylori also impairs the secretion of
bicarbonate, promoting the development of
acidity and gastric metaplasia.
• Regular use of NSAIDs increases the odds of GI bleeding up to 5- to 6-fold * Suppression of
prostaglandin synthesis is the mechanism of injury
• H.pylori infection raised the risk of peptic ulcer bleeding more than 6-fold in patients receiving long-
term NSAIDs
* H.pylori alone and NSAID use alone raised the risk by 1.79-fold and 4.85-fold respectively
* Patients about to start NSAID therapy, eradication of Hp reduces the subsequent risk of ulcer
development **
Clinical Manifestations
Asymptomatic PUD
• Up to 70% of patients with peptic ulcers do not experience symptoms.
• Patients who take NSAIDs are more likely to have asymptomatic ulcers and present with
complications of PUD
Symptomatic PUD
• Abdominal pain
◦ The most common symptom of PUD
◦ Commonly located in the epigastrium
◦ Often described as “gnawing” or “burning”
◦ Can be related to meal intake depending on the location of the ulcer
• Other associated symptoms
◦ Belching
◦ Indigestion
◦ Gastrointestinal reflux
◦ Nausea and/or vomiting
◦ Bloating/abdominal fullness
Alarming features (Red flags)
• Age older than 55 years with new-onset dyspepsia
• Family history of upper GI cancer
• GI bleeding, acute or chronic, including unexplained iron deficiency anemia
• Persistent vomiting
• Progressive dysphagia
• Unintended weight loss
• Jaundice
• Left supraclavicular lymphadenopathy (Virchow’s node)
• Palpable abdominal mass

Diagnosis
• Upper GI Endoscopy: Esophagogastroduodenoscopy (EGD), the gold standered & most accurate.
□ Gastric ulcers are commonly located on the lesser curvature between the antrum and fundus.
□ duodenal ulcers are located in the first part of the duodenum.
• Barium swallow: when EGD is contraindicated.
On endoscopy if ulcer is gastric and there is concern for malignancy biopsies from the edge of the ulcer are
obtained and repeat EGD in 8 weeks
• Biopsies to diagnose H.pylori are obtained during endoscopy
Detailed approach to diagnosis --> https://next.amboss.com/us/article/zg0rB2#RE0lv3
Differential Diagnosis ---> https://next.amboss.com/us/article/zg0rB2#QE0uv3
Management and Treatment https://next.amboss.com/us/article/zg0rB2#jE0_v3

Complications https://next.amboss.com/us/article/zg0rB2#PE0WD3
• Upper gastrointestinal bleeding
• Gastric outlet obstruction
• Perforation
• Penetration
• Gastric cancer