What is a peptic ulcer?

Peptic Ulcer Definition

Peptic ulcer disease is mucosal erosion in the stomach or proximal duodenum caused by acid-peptic damage that exposes underlying tissues to digestive gastroduodenal secretions. 1

Pathophysiology

• Peptic ulceration occurs when acid-peptic damage to the gastroduodenal mucosa results in mucosal erosion that exposes underlying tissues to the digestive action of gastroduodenal secretions 1
• The disease typically occurs in the stomach and proximal duodenum 2
• While traditionally related to hypersecretory acid environment, dietary factors, and stress, the understanding of etiology has evolved significantly 1

Epidemiology

• Peptic ulcer disease has a lifetime prevalence of 5-10% in the general population 1
• Annual incidence is 0.1-0.3% per year 1
• In the United States, approximately 1 in 12 people are affected, with roughly 54,000 hospital admissions annually for bleeding peptic ulcers 3
• Approximately 10% of patients presenting with upper abdominal pain in primary care have peptic ulcer as the cause 3
• Despite sharp reductions in incidence and mortality over the past 30 years, complications still occur in 10-20% of patients 1

Primary Etiologies

The two dominant causes are Helicobacter pylori infection and NSAID use:

• H. pylori is the main causative agent in gastroduodenal ulcer disease, affecting approximately 42% of patients with peptic ulcer disease 4, 3
• NSAIDs and aspirin are the second most important cause, affecting approximately 36% of patients 4, 3
• The combination of H. pylori infection and NSAID use synergistically increases the risk of bleeding ulcers more than sixfold 5
• Corticosteroids represent another pharmacologic cause affecting acid secretion in the gastric mucosa 4

Additional Risk Factors

• Smoking contributes as a modifiable risk factor that alters gastric mucosal integrity 4
• High-salt-content diet contributes to altered gastric mucosal integrity 4
• Alcohol abuse has contributed to changing epidemiology 4
• Stress ulcers occur particularly in critically ill patients in ICU settings or post-surgery 4

Major Complications

Complications occur in three primary forms with distinct frequencies:

• Hemorrhage is the most common complication, occurring in 73% of complicated cases, with annual incidence of 0.02-0.06% and 30-day mortality of 8.6% 6, 3
• Perforation occurs in 9% of complicated cases and carries mortality rates up to 30% if treatment is delayed 6, 3
• Pyloric obstruction occurs in 3% of complicated cases 3
• Chronic fibrotic disease causing gastric outlet obstruction has become uncommon with improved medical management 6

Clinical Presentation

• Most patients with peptic ulcer disease remain asymptomatic 7
• When symptomatic, dyspepsia is the most frequent presentation 7
• Classic symptoms include epigastric discomfort, specifically pain relieved by food intake or antacids, pain causing awakening at night, or pain occurring between meals 2
• Loss of appetite and weight loss may occur 2
• Peptic ulcer is responsible for approximately 10% of upper gastrointestinal symptoms 1

Important Clinical Caveat

• In adults, symptomatic response to therapy with proton pump inhibitors does not preclude the presence of gastric malignancy 8, 9
• Additional follow-up and diagnostic testing should be considered in adult patients with suboptimal response or early symptomatic relapse after completing PPI treatment 8, 9
• In older patients, endoscopy should also be considered 8, 9