Peptic Ulcer Disease

BASICS

Defects in the stomach and/or duodenal mucosa leads to inflammation and erosion of the underlying tissue by gastric acid and pepsin.

Mucosal breaks extending into the submucosa or muscularis propria >3 to 5 mm located in the stomach or duodenum
Peptic ulcer disease (PUD) is an endoscopic diagnosis versus dyspepsia that is a clinical diagnosis.
Helicobacter pylori and aspirin/NSAIDs use are the leading causes of ulcers.
NSAIDs use plus H. pylori infection increases the risk of PUD by 60-fold.
Multiple ulcers/ulcers distal to the second portion of duodenum and/or jejunum raise possibility of gastrinoma (Zollinger-Ellison syndrome [ZES]).
Idiopathic ulcers now account for 20% of PUD (1).

United States: incidence ~500,000 cases/year (2)

Highest prevalence in South Asia
Low and middle income countries have a higher prevalence of H. pylori infections and PUD (1).

H. pylori infection
Long term NSAIDs use
Other medications: corticosteroids, bisphosphonates, potassium chloride, clopidogrel, sirolimus, chemotherapeutic agents, SSRIs
Hypersecretion syndromes: gastrinoma (ZES), systemic mastocytosis, cystic fibrosis, hyperparathyroidism, carcinoid syndrome, antral G-cell hyperplasia
Tobacco, alcohol, stress, radiation therapy, obesity

Limit NSAIDs, aspirin, alcohol, tobacco, caffeine
If NSAIDs are necessary, use the lowest possible dose with a proton pump inhibitor (PPI) or misoprostol. Test for and eradicate H. pylori.
Treat with PPIs or H₂ blockers for patients at risk of complications and recurrence.
Strong association between obesity and PUD; counsel patients on weight loss.

Gastrinoma (ZES); multiple endocrine neoplasia type 1 (MEN 1); carcinoid syndrome

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