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

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

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

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

• 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

• 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