A General Overview of Peptic Ulcer Disease

Introduction – Overview of Peptic Ulcer Disease

Summary

Peptic ulcer disease is a prevalent gastrointestinal pathology that affects a considerable proportion of the global population. The disease results from a multifactorial etiology that involves several contributing factors, including Helicobacter pylori infection, nonsteroidal anti-inflammatory drug use, as well as stress-induced mucosal damage. Peptic ulcer disease can present as gastric, duodenal, or stress-related ulcers, with symptoms including abdominal pain, nausea, and vomiting.

The management and treatment of peptic ulcer disease involve lifestyle modifications, such as diet and stress reduction, along with medications, such as proton pump inhibitors, H2 receptor antagonists, antacids, and antibiotics. Surgical interventions may be required for refractory cases.

Complications of peptic ulcer disease include bleeding, perforation, and obstruction, which can lead to serious consequences if not addressed promptly. Strategies for preventing complications and recurrence include avoiding risk factors, adhering to treatment, and regular follow-up with healthcare providers.

Future directions for research and treatment of peptic ulcer disease may involve the development of new medications with better efficacy and safety profiles, as well as the use of precision medicine approaches to identify patients who may benefit from specific treatments based on their individual characteristics.

Early recognition and prompt treatment of peptic ulcer disease can lead to improved outcomes and a better quality of life for patients.

Peptic ulcer disease (PUD) is a common medical condition affecting the gastrointestinal tract. It is characterized by mucosal damage in the stomach or duodenum and is typically caused by a complex interplay between genetic, environmental, and infectious factors (1). PUD is a significant health problem with a high incidence and prevalence worldwide, and if left untreated, it can lead to potentially life-threatening complications (2).

The most common symptoms of PUD include pain in the epigastric region, nausea, and vomiting (3). While some individuals with PUD may remain asymptomatic, others may develop severe complications, such as bleeding, perforation, or obstruction (4). Infection with Helicobacter pylori, a bacterium that colonizes the gastric mucosa, is a leading cause of PUD (5). Other factors contributing to the development of PUD include chronic use of non-steroidal anti-inflammatory drugs (NSAIDs), smoking, and excessive alcohol consumption (6, 7).

Early diagnosis and treatment of PUD are crucial in preventing serious complications. In general, the treatment of peptic ulcer disease involves a combination of medications aimed at both reducing acid secretion and eliminating H. pylori infection along with lifestyle modifications. In some cases, surgical intervention may be necessary (1, 2).

As a common medical condition, PUD requires medical professionals to be familiar with its diagnosis, management, and potential complications. This article will provide an overview of PUD, including its incidence and prevalence rates, etiology, clinical presentation, diagnosis, and management. 

Epidemiology of Peptic Ulcer Disease

Peptic ulcer disease (PUD) is a relatively common condition worldwide, with a significant burden on healthcare resources. The epidemiology of PUD varies across different regions and populations.

The prevalence of PUD has been decreasing in recent years (8), likely due to the widespread use of proton pump inhibitors and the eradication of H. pylori. In the United States, the estimated prevalence of PUD is 6 million cases per year, with a lifetime prevalence of 10% (9). PUD affects both men and women equally, and the incidence increases with age. The incidence of PUD is higher in developing countries and areas with poor sanitation and hygiene. H. pylori infection is the leading cause of PUD in these regions (10), whereas NSAID use is a more significant risk factor in developed countries (1). 

Etiologies and Risk Factors for Peptic Ulcer Disease

Peptic ulcer disease (PUD) is a multifactorial condition with several etiologies and risk factors (11). Peptic ulcer disease is most commonly attributed to the following factors (1):

Helicobacter Pylori Infection

H. pylori is a bacterium that colonizes the gastric mucosa and is a leading cause of PUD (12). Infection with H. pylori causes an inflammatory response in the gastric mucosa, leading to the development of ulcers.

Non-steroidal Anti-inflammatory Drugs (NSAIDs)

The use of nonsteroidal anti-inflammatory drugs (NSAIDs) is widespread for the management of pain and inflammation. Prolonged or excessive use of these drugs can lead to gastric mucosal damage and the subsequent development of ulcers (13).

Stress-related Mucosal Damage

Physiological stress, such as that caused by severe illness, trauma, or surgery, can increase the risk of developing PUD (1, 14).

Smoking

Smoking increases the risk of developing PUD by reducing the protective properties of the gastric mucosa (1, 6, 7).

Alcohol Consumption

Alcohol consumption can increase the risk of developing PUD by increasing gastric acid secretion and reducing the protective properties of the gastric mucosa (6, 7).

Other Risk Factors

Other factors that increase the risk of developing PUD include advanced age, family history of PUD, and underlying medical conditions such as cirrhosis, chronic obstructive pulmonary disease (COPD), and chronic kidney disease (CKD) (1, 15).

Pathophysiology of Peptic Ulcer Disease

Peptic ulcer disease (PUD) is a condition characterized by the development of mucosal damage in the stomach or duodenum (1). To understand the pathophysiology of PUD, it is important first to understand the role of the stomach in digestion.

Overview of the Digestive System and the Role of the Stomach in Digestion

The gastrointestinal tract represents a highly intricate network of organs responsible for the process of digestion, whereby ingested food is enzymatically degraded into constituent nutrients that can be subsequently assimilated and utilized by the body. The stomach plays a crucial role in this process by secreting acid and enzymes that help to break down food (16, 17).

When food enters the stomach, it is mixed with gastric acid and digestive enzymes, forming a semi-liquid mixture called chyme. Subsequently, the stomach undergoes peristaltic contractions, which serve to mix and grind the ingested food into a more homogeneous mixture. This chyme is subsequently emptied into the duodenum, undergoing further enzymatic digestion and nutrient absorption. (17, 18).

Mechanisms Underlying the Development of Peptic Ulcer Disease

The development of PUD is a complex process that involves the interplay between various genetic, environmental, and infectious factors (1). The following mechanisms are thought to contribute to the development of PUD:

Disruption of the Gastric Mucosal Barrier

The gastric mucosal barrier is a protective layer that lines the stomach and prevents acid and digestive enzymes from damaging the underlying tissue. Disruption of this barrier can lead to mucosal damage and the development of ulcers (1).

Increased Acid Secretion

Excessive acid secretion in the stomach can lead to the development of PUD. This can be caused by H. pylori infection, stress-related mucosal damage, or the use of NSAIDs (1,19).

Impaired Mucosal Blood Flow

Impaired blood flow to the gastric mucosa can lead to tissue damage and the development of ulcers. This can be caused by physiological stress, hypotension, or impaired blood flow to the gastric mucosa (20).

Interactions Between H. pylori Infection, NSAIDs, and Stress-Related Mucosal Damage

H. pylori infection, NSAID use, and physiological stress are the most common factors that contribute to the development of PUD. These factors can interact with each other, leading to the development of more severe and complicated ulcers (2).

According to the research (21), Infection with Helicobacter pylori (H. pylori) has been implicated as a causative factor in the development of gastric ulcers by inducing a state of chronic inflammation within the gastric mucosa. NSAID use can also cause mucosal damage and increase the risk of developing ulcers (22). Stress-related mucosal damage can further exacerbate the development of ulcers by impairing the blood flow to the gastric mucosa (23).

Classification and Diagnosis

Peptic ulcer disease (PUD) can be classified based on the location of the ulcer as well as the underlying etiology. The three main types of PUD include (24):

Gastric Ulcer

Gastric ulceration pertains to the development of open sores or wounds in the lining of the stomach.

Duodenal Ulcers

Duodenal ulceration denotes a similar pathological process in the upper part of the small intestine, namely, the duodenum.

Clinical Presentation and Symptoms of Peptic Ulcer Disease

The clinical manifestation of peptic ulcer disease (PUD) may exhibit significant variations based on the precise site and severity of the ulcerative lesion. The most common symptoms of PUD include (1, 2, 24):

• Abdominal pain:

The pain is usually located in the epigastric region and is described as a burning or gnawing sensation.

• Nausea and vomiting:

These symptoms may occur in some patients, especially if the ulcer is located in the stomach.

• Weight loss:

Chronic PUD may lead to weight loss due to a loss of appetite.

• Hematemesis or melena:

In severe cases, PUD can lead to bleeding, which may present as blood in vomiting (hematemesis) or black, tarry stools (melena).

Diagnostic Methods

The diagnosis of peptic ulcer disease (PUD) commonly necessitates a comprehensive diagnostic approach involving a blend of clinical assessment, endoscopic examination, and an array of pertinent laboratory investigations (25, 26, 27). The following diagnostic methods may be used:

Endoscopy

The procedure entails the insertion of a flexible endoscopic tube into the oral cavity, which is then advanced into the stomach, allowing for direct visualization of the ulcerative lesion and enabling the acquisition of biopsy specimens for subsequent laboratory analysis. Endoscopy can also be used to rule out other diseases. As esophageal varices can also present with hematemesis, endoscopy also helps in ruling out esophageal varices, among other diseases.

Biopsy

A small tissue sample is taken from the ulcer and examined under a microscope for signs of inflammation or infection. Biopsy can also be useful in ruling out other conditions that may have similar symptoms, such as malignancy, atrophic gastritis, and other potential conditions. Therefore, biopsy plays a crucial role in accurately diagnosing peptic ulcer disease and ruling out other possible conditions that may require different treatment approaches.

Serology

Blood tests can detect the presence of antibodies to H. pylori, indicating a current or previous infection. Blood tests can also be used to rule out other diseases such as serum gastrin level can be used to rule out Zollinger-Ellison syndrome and is the gold standard test. Zollinger-Ellison syndrome also presents with the same complaints and should be ruled out.

Urea breath test

A non-invasive test that measures the presence of H. pylori in the stomach by detecting the production of urease enzyme in response to a urea substrate.

Ultrasound Abdomen

Ultrasound abdomen can also be done to rule out other conditions, such as cholecystitis and cholelithiasis, which can also present with epigastric pain, nausea, and vomiting. Moreover, an ultrasound abdomen can also be used to check if there is any free fluid in the abdominal cavity which is the indication for perforation of viscera (which is the complication of peptic ulcer disease).

ECG

If the patient presents with severe pain in the epigastrium, it may also be due to myocardial infarction of the inferior wall, which usually radiates to the epigastrium. ECG is the quickest way to assess for myocardial infarction. As it is an emergency condition, it should always be suspected and ruled out.

Management and Treatment of Peptic Ulcer Disease

The treatment of peptic ulcer disease (PUD) typically involves a combination of lifestyle modifications, medications, and in some cases, surgical interventions (1).

Lifestyle modifications

Lifestyle modifications can be an effective way to manage PUD and prevent symptoms from worsening. The following lifestyle changes may be recommended (28):

• Diet modification:

Avoiding foods and drinks that can irritate the stomach lining, such as spicy foods, alcohol, and caffeine.

• Stress reduction:

Reducing stress levels through relaxation techniques or stress management strategies can help manage PUD symptoms.

• Smoking cessation:

Smoking can worsen PUD symptoms and increase the risk of complications, so quitting smoking is recommended.

• Alcohol avoidance:

Alcohol consumption can irritate the stomach lining and increase the risk of complications, so avoiding alcohol is recommended.

Medications

The medications (29) used for the treatment of peptic ulcer disease include:

• Proton Pump Inhibitors (PPIs):

PPIs work by reducing the amount of acid produced by the stomach. PPIs bind to and inhibit the hydrogen-potassium ATPase enzyme, also known as the proton pump, which is responsible for pumping hydrogen ions into the stomach to produce stomach acid. By inhibiting the proton pump, PPIs reduce the production of acid in the stomach, thereby increasing the pH of the stomach contents.

PPIs are also known to inhibit basal acid secretion, which occurs even in the absence of food intake (30).

By reducing the amount of acid in the stomach, PPIs can provide relief from symptoms such as heartburn, acid regurgitation, and stomach pain. PPIs are also effective in promoting the healing of damaged or inflamed tissue in the esophagus or stomach caused by acid-related disorders (31).

Examples include omeprazole, lansoprazole, and esomeprazole (29).

• H2 Receptor Antagonists:

These drugs block the action of histamine, which stimulates acid production in the stomach. Examples include cimetidine, ranitidine, and famotidine (32).

• Antacids:

These drugs neutralize stomach acid and provide immediate relief of symptoms. Examples include aluminum hydroxide, magnesium hydroxide, and calcium carbonate (29, 32).

• Antibiotics:

In cases where H. pylori infection is present, eradication therapy is usually used. In this therapy, antibiotics such as amoxicillin, clarithromycin, and metronidazole may be prescribed along with PPIs (33).

Eradication Therapy

It is an important treatment strategy for peptic ulcer disease. The most commonly used regimens for H. pylori eradication are the triple therapy regimen and the quadruple therapy regimen.

Triple Therapy Regimen: This regimen includes the use of a proton pump inhibitor (PPI) and two antibiotics, usually clarithromycin and amoxicillin or metronidazole. The dosages and duration of therapy may vary, but a common regimen is (34):

• PPI (such as omeprazole) twice daily for 14 days
• Clarithromycin 500 mg twice daily for 14 days
• Amoxicillin 1 g twice daily for 14 days

Quadruple Therapy Regimen: This regimen includes the use of a PPI, bismuth subsalicylate, and two antibiotics, usually metronidazole and tetracycline. The dosages and duration of therapy may vary, but a common regimen is (35):

• PPI (such as omeprazole) twice daily for 14 days
• Bismuth subsalicylate 525 mg four times daily for 14 days
• Metronidazole 500 mg three times daily for 14 days
• Tetracycline 500 mg four times daily for 14 days

The duration of therapy for both regimens is typically 14 days, but in some cases, it may vary as 10-14 days. It is important to complete the full course of therapy to ensure the effective eradication of the H. pylori infection.

Surgical Interventions

In cases where medical therapy fails, there is a complication such as bleeding or perforation of the ulcer, surgery may be necessary (36). Surgical interventions include:

• Vagotomy:

This procedure involves cutting the vagus nerve, which controls the secretion of acid in the stomach (30). However, vagotomy is not the preferred treatment for peptic ulcer disease nowadays due to the potential side effects such as delayed gastric emptying, diarrhea, dumping syndrome, nutritional deficiencies, and weight gain. It is generally reserved for cases in which other treatments have failed or for certain types of ulcers that are resistant to other treatments (37).

• Antrectomy:

This surgical procedure involves the excision of the distal portion of the stomach, which is responsible for producing gastrin, a hormone that plays a vital role in stimulating gastric acid secretion (38).

• Pyloroplasty:

This procedure involves widening the opening between the stomach and the small intestine to allow food to pass more easily (39).

• Gastrectomy: 

This procedure involves removing part or all of the stomach (40).

Prognosis and Complications of Peptic Ulcer Disease

Peptic ulcer disease has a good prognosis with appropriate management and treatment. Most patients experience complete healing of ulcers within 4-8 weeks of treatment initiation (1, 30). The recurrence rates can be high if preventive measures are not taken. Long-term outcomes of peptic ulcer disease depend on the underlying cause and the patient’s overall health status (1-2).

Complications of peptic ulcer disease include bleeding, perforation, and obstruction. Bleeding can occur from the ulcer site and can result in anemia and shock if left untreated. Perforation occurs when the ulcer penetrates through the stomach or duodenal wall, leading to the leakage of gastric contents into the abdominal cavity or severe bleeding associated with Duodenal artery injury. This can cause severe pain and inflammation, leading to a medical emergency. 

Obstruction can occur if the ulcer is located at the pylorus, the junction between the stomach and duodenum, leading to blockage of the digestive tract (41).

Disclosures

The author does not report any conflict of interest.

Disclaimer

This information is for educational purposes and is not intended to treat disease or supplant professional medical judgment. Physicians should follow local policy regarding the diagnosis and management of medical conditions.

See Also

Malabsorption Syndromes

Acute Diarrhea in Adults

Acute Abdomen

Common Exanthematous Diseases of Childhood

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