Peptic Ulcer Disease

Peptic Ulcer Disease is a topic covered in the 5-Minute Clinical Consult.

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Basics

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.

Description

  • 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

Epidemiology

Incidence
  • 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%

Prevalence
  • 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

Genetics
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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