What is peptic ulcer disease?

What is Peptic Ulcer Disease?

Peptic ulcer disease is a condition where acid-peptic damage to the gastroduodenal mucosa results in mucosal erosion that exposes underlying tissues to digestive secretions, occurring in the stomach and proximal duodenum with a lifetime prevalence of 5-10% in the general population. 1

Pathophysiology

• Peptic ulceration develops when gastroduodenal secretions erode through the protective mucosal layer, exposing deeper tissues to acid and pepsin 1
• The disease was historically attributed to hypersecretory acid states, dietary factors, and stress, but modern understanding identifies specific causative factors 1
• The mucosa normally maintains a protective barrier; when this fails, ulceration occurs in areas exposed to acid-peptic secretions 1

Primary Causes

The two dominant causes are Helicobacter pylori infection and nonsteroidal anti-inflammatory drug (NSAID) use, which together account for the vast majority of cases. 1, 2

• H. pylori infection is present in approximately 1 in 5 peptic ulcers in the United States 2
• NSAID use accounts for most of the remaining cases 2, 3
• The combination of H. pylori infection and NSAID use synergistically increases bleeding ulcer risk more than sixfold 2
• Additional risk factors include alcohol abuse and smoking 1

Epidemiology

• Annual incidence ranges from 0.1-0.3% per year 1
• Affects approximately 1 in 12 people in the United States during their lifetime 2
• Despite a sharp reduction in incidence over the past 30 years, complications still occur in 10-20% of patients 1
• The disease consumes considerable healthcare resources and may involve multiple subspecialties 1

Clinical Presentation

Most patients (approximately two-thirds) with peptic ulcer disease remain asymptomatic. 4

When symptomatic, patients typically present with:

• Epigastric discomfort or pain, specifically pain relieved by food intake or antacids 3
• Pain that awakens patients at night or occurs between meals 3
• Dyspepsia, bloating, and abdominal fullness 5, 4
• Loss of appetite and weight loss 3, 5
• Nausea and vomiting 6
• Postprandial abdominal pain 6

Major Complications

Peptic ulcer disease has four major complications: bleeding (73% risk), perforation (9% risk), gastric outlet obstruction (3% risk), and penetration. 7

Hemorrhage

• Most frequent complication with annual incidence of 0.02-0.06% in the general population 7
• Carries a 30-day mortality of 8.6% 1, 7
• Most common indication for hospitalization among ulcer complications 1

Perforation

• Less common with annual incidence of 0.004-0.014% 1, 7
• Carries the highest mortality at 23.5% and accounts for approximately 40% of all ulcer-related deaths 8, 7
• Most common indication for emergency surgery despite being less frequent than bleeding 1, 7
• The perforation-to-bleeding ratio is approximately 1:6 1, 7
• Presents with sudden onset of severe abdominal pain, though peritonitis is present in only two-thirds of patients 8
• Every hour of delay from admission to surgery decreases survival probability by 2.4% 8

Gastric Outlet Obstruction

• Now rare due to improved medical management 1
• Results from chronic fibrotic disease 1

Historical Context and Impact

• In the 1970s, there were 500,000 new cases annually in the United States, with over 400,000 hospitalizations and 4 million hospital days 1
• Peptic ulcers were responsible for 140,000 operations and 9,000 hospital deaths per year 1
• The disease was chronic with the adage "once an ulcer, always an ulcer" before H. pylori discovery 1
• Discovery of H. pylori in the early 1980s transformed peptic ulcer from a chronic disease into a curable condition 1

Distinction from Inflammatory Bowel Disease

Peptic ulcer disease is fundamentally different from inflammatory bowel disease (IBD), which includes Crohn's disease and ulcerative colitis with distinct pathophysiology involving immune-mediated inflammation rather than acid-peptic damage 1, 7