Peptic Ulcer Disease

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Peptic ulcer disease is characterized by defects in the stomach and/or duodenal mucosa through the muscularis mucosa, leading to inflammation of the underlying tissue by gastric acid and pepsin.


  • Duodenal ulcer
    • Most common form of peptic ulcer
    • Usually located in the proximal duodenum
    • Multiple ulcers or ulcers distal to the second portion of duodenum raise possibility of gastrinoma (Zollinger-Ellison syndrome).
  • Gastric ulcer
    • Less common than duodenal ulcer in absence of NSAID use
    • Commonly 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


  • Predominant sex: male = female
  • 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%

  • Peptic ulcer: 2% in the United States
  • The lifetime prevalence is higher (10–20%) in Helicobacter pyloripositive patients, compared to the general population (5–10%).

Etiology and Pathophysiology

Increased incidence of PUD in families is likely due to familial clustering of H. pylori infection and inherited genetic factors reflecting response to the organism.

Risk Factors

  • H. pylori infection (95% of duodenal and 70% of gastric ulcers)
  • Chronic use of NSAIDs, including aspirin and COX-2 inhibitors
  • Tobacco use
  • Stress (after acute illness, ventilator support, extensive burns, head injury)
  • Hypersecretion syndromes: gastrinoma (Zollinger-Ellison), systemic mastocytosis, carcinoid syndrome; alcohol use
  • Medications: corticosteroids (high-dose and/or prolonged therapy), bisphosphonates, potassium chloride, clopidogrel, sirolimus chemotherapeutic agents
  • Radiation therapy

General Prevention

  • NSAID ulcers: Use acetaminophen (instead of NSAIDs) when appropriate, and discontinue NSAID use (or add a proton pump inhibitor [PPI]) in patients with previous NSAID-related ulcer.
    • If NSAIDs are absolutely necessary, use lowest possible dose to decrease risk of ulcerogenesis and use in combination with a PPI or misoprostol.
    • To reduce ulcer risk, consider testing for and eradicating H. pylori, particularly before starting therapy with NSAIDs.
  • Maintenance therapy with PPIs or H2 blockers is indicated for patients with a 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 H. pylori infection: ≤1%

Commonly Associated Conditions

  • Gastrinoma (Zollinger-Ellison syndrome)
  • Multiple endocrine neoplasia type 1
  • Carcinoid syndrome
  • Chronic illness: Crohn disease, chronic obstructive pulmonary disease (COPD), chronic renal failure, hepatic cirrhosis, cystic fibrosis
  • Hematopoietic disorders (rare): systemic mastocytosis, myeloproliferative disease, hyperparathyroidism, polycythemia rubra vera

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