Peptic Ulcer Disease
Basics
Basics
Basics
Peptic ulcer disease (PUD) is characterized by defects in the stomach and/or duodenal mucosa, leading to inflammation of the underlying tissue by gastric acid and pepsin.
Description
Description
Description
- Duodenal ulcer: most common form of PUD; usually located in the proximal duodenum
- Multiple ulcers/ulcers distal to the second portion of duodenum and/or jejunum raise possibility of gastrinoma (Zollinger-Ellison syndrome [ZES]).
- Gastric ulcer: less common than duodenal ulcer in absence of NSAID use; often located along lesser curvature of the antrum
- Esophageal ulcers: located in the distal esophagus; usually secondary to gastroesophageal reflux disease (GERD); also seen with gastrinoma
- Ectopic gastric mucosal ulceration: may develop with Meckel diverticulum
Epidemiology
Epidemiology
Epidemiology
The incidence and prevalence have decreased in high-income countries including United States (1).
Incidence
- Duodenal ulcers: more common in men
- Predominant age: 70% of ulcers occur between ages 25 and 64 years. Duodenal/gastric ulcer incidence increases with age.
- Peptic ulcer: 500,000 new cases per year
- Recurrence: 4 million per year
- Global incidence rate 0.1–0.19%; overall decrease from improved sanitary conditions, effective treatment, and careful NSAIDs use
- Lifetime risk globally: 5–10%
Prevalence
<10% in the general population; lifetime prevalence is higher (10–20%) in Helicobacter pylori–positive patients, compared to the general population (5–10%).
Etiology and Pathophysiology
Etiology and Pathophysiology
Etiology and Pathophysiology
Genetics
Increased incidence in families due to familial clustering of H. pylori infection and inherited genetic factors reflecting response to organism.
Risk Factors
Risk Factors
Risk Factors
- Most common cause: H. pylori infection
- NSAIDs use (including aspirin and COX-2 inhibitors): second most common cause; those with regular use have risk of concomitant H. pylori infection.
- Other medication use: corticosteroids (high dose; prolonged therapy), bisphosphonates, potassium chloride, clopidogrel, sirolimus chemotherapeutic agents
- Hypersecretion syndromes: gastrinoma (ZES), systemic mastocytosis, cystic fibrosis, hyperparathyroidism, carcinoid syndrome, antral G-cell hyperplasia
- Others: tobacco use, alcohol use, stress (e.g., acute illness, ventilator support, extensive burns, head injury), radiation therapy
General Prevention
General Prevention
General Prevention
- Educate patients about harmful agents like NSAIDs, aspirin, alcohol, tobacco, and caffeine.
- Discontinue NSAIDs and use acetaminophen instead when appropriate, or add proton pump inhibitor (PPI) in patients with previous NSAID-related ulcer.
- If NSAIDs are necessary, use the lowest possible dose with a PPI or misoprostol.
- To reduce ulcer risk, consider testing for and eradicating H. pylori.
- Maintenance therapy with PPIs or H2 blockers: indicated if history of ulcer complications, recurrences, refractory ulcers, or persistent H. pylori infection
- Consider maintenance PPI treatment in patients with H. pylorinegative, non–NSAID-induced ulcer.
- H. pylori infection: present in 95% of duodenal and 70% of gastric ulcers; annual risk of duodenal ulcer in those with infection is ≤1%.
- Strong association exists between obesity and PUD; counsel patients on weight loss
Commonly Associated Conditions
Commonly Associated Conditions
Commonly Associated Conditions
- Gastrinoma (ZES); multiple endocrine neoplasia type 1; carcinoid syndrome
- Chronic illness: Crohn disease, chronic obstructive pulmonary disease, chronic renal failure, hepatic cirrhosis, cystic fibrosis
- Hematopoietic disorders (rare): systemic mastocytosis, myeloproliferative disease, hyperparathyroidism, polycythemia rubra vera
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