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.
- 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
- 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