Peptic Ulcer Disease

Peptic ulcers are open sores that develop when the protective mucous layer of the digestive tract is eroded, exposing the underlying tissue to stomach acid and digestive enzymes. These ulcers most commonly occur in the first part of the small intestine (duodenal ulcers) or in the stomach itself (gastric ulcers). Less commonly, they can occur in the esophagus or beyond the duodenum.

The discovery that most ulcers are caused by Helicobacter pylori bacteria revolutionized treatment in the 1980s. Before this, ulcers were thought to be caused primarily by stress and spicy foods, leading to treatments that provided only temporary relief. We now know that H. pylori infection and nonsteroidal anti-inflammatory drugs (NSAIDs) account for over 90% of peptic ulcers.

The stomach normally produces acid to help digest food and kill bacteria. To protect itself, the stomach and duodenum produce a thick layer of mucus and other protective factors. When this protective barrier is compromised - whether by H. pylori, NSAIDs, or other factors - acid can erode the lining, creating an ulcer. Understanding this mechanism has led to highly effective treatments that not only heal ulcers but prevent their recurrence.

By Location

Duodenal Ulcers

• Most common type (70% of cases)
• Occur in first part of small intestine
• Pain often improves with eating
• Pain worse 2-3 hours after meals
• May wake patient at night (1-3 AM)
• More common in younger patients
• Strong association with H. pylori

Gastric Ulcers

• Occur in stomach lining
• Pain may worsen with eating
• Nausea and weight loss more common
• Higher risk of malignancy (requires biopsy)
• More common in elderly
• Often associated with NSAIDs

Esophageal Ulcers

• Rare, usually from severe GERD
• Pain with swallowing
• Chest pain
• May be associated with medications

By Cause

H. pylori-Associated Ulcers

• 60-90% of duodenal ulcers
• 60-70% of gastric ulcers
• Require antibiotic treatment
• Lower recurrence after eradication

NSAID-Induced Ulcers

• Second most common cause
• Often asymptomatic until complications
• More likely to bleed
• Risk increases with dose and duration

Stress Ulcers

• Occur in critically ill patients
• ICU setting, severe burns, major surgery
• Different mechanism than typical PUD
• Prophylaxis often given in ICU

Zollinger-Ellison Syndrome

• Rare cause (<1%)
• Gastrin-producing tumor
• Multiple, recurrent ulcers
• Ulcers in unusual locations
• Severe symptoms

Pain Characteristics

Duodenal Ulcer Pain

• Burning or gnawing sensation
• Located in upper abdomen
• Occurs 2-3 hours after eating
• Often wakes patient at night
• Relieved by food or antacids
• Episodic - weeks of pain, then remission

Gastric Ulcer Pain

• Pain immediately after eating
• Food may worsen pain
• Less likely to wake at night
• May cause food aversion
• Associated with nausea

Silent Ulcers

Important: Up to 70% of NSAID-induced ulcers cause no symptoms until complications occur.

Primary Causes

Helicobacter pylori Infection

• Spiral-shaped bacteria
• Lives in stomach mucus layer
• Produces urease enzyme
• Damages protective mucus
• Triggers inflammation
• Transmitted person-to-person
• Often acquired in childhood
• 50% of world population infected
• Only 10-20% develop ulcers

NSAIDs (Nonsteroidal Anti-inflammatory Drugs)

• Aspirin, ibuprofen, naproxen
• Inhibit prostaglandin production
• Reduce protective mucus
• Decrease blood flow to stomach
• Direct toxic effect on cells
• Risk increases with:
  • Higher doses
  • Longer duration
  • Multiple NSAIDs
  • Concurrent corticosteroids

Risk Factors

For H. pylori Ulcers

• Living in developing countries
• Crowded living conditions
• Poor sanitation
• Contaminated water
• Family history
• Lower socioeconomic status

For NSAID Ulcers

• Age over 65
• Previous ulcer history
• High-dose NSAIDs
• Concurrent medications:
  • Corticosteroids
  • Anticoagulants
  • SSRIs
  • Multiple NSAIDs
• Serious systemic illness
• H. pylori co-infection

Other Contributing Factors

• Smoking: Increases risk and delays healing
• Alcohol: Can erode mucous lining
• Stress: May worsen symptoms
• Genetics: Family history increases risk
• Blood type O: Higher risk for duodenal ulcers
• Rare causes:
  • Zollinger-Ellison syndrome
  • Crohn's disease
  • Cancer (gastric lymphoma)
  • Radiation therapy

Myths About Ulcer Causes

These do NOT cause ulcers but may worsen symptoms:

• Spicy foods
• Coffee
• Emotional stress alone
• Personality type
• Eating quickly

Without treatment, peptic ulcers can lead to serious complications:

Bleeding (15% of patients)

• Most common complication
• Can be slow or rapid
• Signs include:
  • Vomiting blood (hematemesis)
  • Black, tarry stools (melena)
  • Anemia symptoms
  • Fatigue and weakness
  • Dizziness when standing
• May require endoscopy
• Blood transfusion if severe

Perforation (5-10% of patients)

• Hole through stomach/duodenal wall
• Medical emergency
• Sudden, severe pain
• Rigid abdomen
• Signs of shock
• Requires immediate surgery
• Higher mortality rate

Obstruction (2% of patients)

• Swelling or scarring blocks passage
• Usually at pylorus
• Symptoms:
  • Recurrent vomiting
  • Feeling full quickly
  • Bloating
  • Weight loss
  • Vomiting undigested food
• May require endoscopic dilation
• Surgery if severe

Penetration

• Ulcer erodes into adjacent organs
• Usually pancreas (duodenal)
• Pain radiates to back
• Pain not relieved by antacids
• May cause pancreatitis

Malignancy Risk

• Gastric ulcers: 2-5% are malignant
• Duodenal ulcers: Rarely malignant
• H. pylori increases gastric cancer risk
• Requires biopsy and follow-up

Clinical Evaluation

• Detailed history of symptoms
• Medication review (NSAIDs)
• Physical examination
• Epigastric tenderness
• Signs of complications

Tests for H. pylori

Non-invasive Tests

• Urea breath test:
  • Most accurate non-invasive test
  • 95% sensitivity and specificity
  • Drink labeled urea solution
  • Measure CO2 in breath
• Stool antigen test:
  • Detects H. pylori proteins
  • Good for initial diagnosis
  • Confirms eradication
• Blood antibody test:
  • Less accurate
  • Remains positive after treatment
  • Not for follow-up

Invasive Tests (During Endoscopy)

• Rapid urease test: Quick results
• Histology: Gold standard
• Culture: For antibiotic resistance

Endoscopy (Gastroscopy)

Indications for endoscopy:

• Age >50 with new symptoms
• Alarm symptoms:
  • Bleeding
  • Anemia
  • Weight loss
  • Difficulty swallowing
  • Persistent vomiting
  • Mass on exam
• Failed empiric therapy
• History of gastric ulcer
• Family history of gastric cancer

Imaging Studies

• Upper GI series: Less commonly used
• CT scan: If perforation suspected
• Chest X-ray: Free air under diaphragm

Laboratory Tests

• Complete blood count (anemia)
• Liver function tests
• Amylase/lipase (if penetration)
• Fasting gastrin (if ZE syndrome suspected)

Treatment aims to relieve pain, heal the ulcer, prevent complications, and prevent recurrence:

H. pylori Eradication Therapy

Triple Therapy (14 days)

• PPI (omeprazole, lansoprazole) twice daily
• Clarithromycin 500mg twice daily
• Amoxicillin 1g twice daily
• OR Metronidazole 500mg twice daily (if penicillin allergic)
• Success rate: 70-85%

Quadruple Therapy (10-14 days)

• PPI twice daily
• Bismuth subsalicylate four times daily
• Metronidazole 250mg four times daily
• Tetracycline 500mg four times daily
• Used if triple therapy fails
• Success rate: 85-90%

Acid Suppression Therapy

Proton Pump Inhibitors (PPIs)

• First-line for healing ulcers
• Examples:
  • Omeprazole 20-40mg daily
  • Lansoprazole 15-30mg daily
  • Esomeprazole 20-40mg daily
  • Pantoprazole 40mg daily
• Duration: 4-8 weeks for duodenal
• 8-12 weeks for gastric ulcers
• Healing rates >90%

H2 Receptor Blockers

• Alternative if PPIs not tolerated
• Famotidine 40mg at bedtime
• Ranitidine (no longer available)
• Less effective than PPIs

For NSAID-Related Ulcers

• Stop NSAIDs if possible
• PPI therapy for 8-12 weeks
• If NSAIDs must continue:
  • Use lowest effective dose
  • Add PPI or misoprostol
  • Consider COX-2 selective NSAID
  • Switch to acetaminophen if possible

Lifestyle Modifications

• Stop smoking: Impairs healing
• Limit alcohol: Especially with active ulcer
• Stress management: May help symptoms
• Diet: No specific restrictions needed
• Avoid NSAIDs: Use alternatives
• Regular meals: Don't skip meals

Follow-up Care

• Confirm H. pylori eradication 4+ weeks after treatment
• Endoscopy for gastric ulcers to ensure healing
• Monitor for symptom recurrence
• Annual testing if high risk

Surgical Treatment

Rarely needed but indicated for:

• Perforation
• Uncontrolled bleeding
• Obstruction not responding to medical therapy
• Suspected malignancy
• Failed medical therapy (rare)

Primary Prevention

• H. pylori prevention:
  • Good hygiene practices
  • Clean water sources
  • Proper food handling
  • Handwashing
• NSAID precautions:
  • Use lowest effective dose
  • Shortest duration possible
  • Consider alternatives
  • Take with food

Secondary Prevention (Recurrence)

• Complete H. pylori eradication therapy
• Confirm eradication with testing
• Long-term PPI if NSAIDs required
• Regular monitoring if high risk
• Avoid smoking
• Limit alcohol
• Manage other risk factors

For High-Risk Patients

• Previous ulcer history
• Elderly on NSAIDs
• Concurrent corticosteroids
• Anticoagulant therapy
• Consider prophylactic PPI
• Regular screening

Daily Management

• Take medications as prescribed
• Complete full course of antibiotics
• Don't stop PPIs abruptly
• Keep symptom diary
• Identify trigger foods
• Maintain regular eating schedule

Dietary Considerations

No specific diet required, but these may help:

• Eat smaller, frequent meals
• Avoid foods that trigger symptoms
• Limit caffeine if bothersome
• Reduce alcohol intake
• Stay hydrated
• Include probiotics (yogurt)

Pain Management

• Use acetaminophen instead of NSAIDs
• Antacids for occasional relief
• Avoid aspirin-containing products
• Discuss pain alternatives with doctor
• Consider physical therapy for arthritis

When to Contact Doctor

• Symptoms persist despite treatment
• New or worsening symptoms
• Signs of bleeding
• Difficulty swallowing
• Unintended weight loss
• Need for NSAIDs

Healing Rates

• With PPI therapy: >90% heal within 4-8 weeks
• H. pylori eradication: 95% remain ulcer-free
• Faster healing with:
  • Smoking cessation
  • NSAID discontinuation
  • Medication compliance
  • Younger age

Recurrence Rates

• Without H. pylori treatment: 60-90% within 1 year
• After successful eradication: <5% per year
• NSAID ulcers: High if NSAIDs continued
• With maintenance PPI: <10% recurrence

Long-term Outlook

• Excellent with proper treatment
• Most patients become symptom-free
• Quality of life returns to normal
• Complications rare with treatment
• Cancer risk minimal after H. pylori eradication