What is peptic ulcer disease?

What is Peptic Ulcer Disease?

Peptic ulcer disease is a condition characterized by mucosal erosion in the stomach or proximal duodenum caused by acid-peptic damage that exposes underlying tissues to digestive secretions, with a lifetime prevalence of 5-10% in the general population. 1

Pathophysiology

Peptic ulceration occurs when acid-peptic damage breaches the gastro-duodenal mucosa, creating erosions that expose underlying tissues to the corrosive action of gastric and duodenal secretions. 1 This process was historically attributed to hypersecretory acid states, dietary factors, and stress, but the understanding has evolved significantly. 1

Primary Etiologic Factors

The two predominant causes in the United States are:

• Helicobacter pylori infection - affects approximately 42% of patients with peptic ulcer disease and is now the main causative agent in gastroduodenal ulcer disease worldwide. 2, 3
• NSAID/Aspirin use - represents the second most important cause, affecting approximately 36% of patients with peptic ulcer disease by altering acid secretion in the gastric mucosa. 2, 3

Additional contributing factors include:

• Corticosteroid use, which affects gastric mucosal acid secretion 2
• Smoking, which alters gastric mucosal integrity 2
• Alcohol abuse 2
• High-salt-content diet 2

Epidemiology

• Lifetime prevalence: 5-10% in the general population 1
• Annual incidence: 0.1-0.3% per year 1
• In the US, approximately 1% of the population is affected, with 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 disease as the underlying cause 3
• Despite a sharp reduction in incidence and mortality over the past 30 years, complications still occur in 10-20% of patients 1

Clinical Presentation

Approximately two-thirds of patients with peptic ulcer disease are asymptomatic. 4

In symptomatic patients, the cardinal manifestation is:

• Epigastric pain - the most common presenting symptom, which may be associated with dyspepsia, bloating, abdominal fullness, nausea, or early satiety 4
• Postprandial abdominal pain 5
• Pain relieved by food intake or antacids 6
• Nocturnal pain or pain that awakens patients at night 6
• Pain occurring between meals 6
• Loss of appetite and weight loss 6

Major Complications

Peptic ulcer disease can lead to three serious complications:

• Hemorrhage - the most common complication, occurring in 73% of complicated cases, with an annual incidence of 0.02-0.06% and a 30-day mortality of 8.6% 1, 3
• Perforation - occurs in 9% of complicated cases, with an annual incidence of 0.004-0.014% and a 30-day mortality of 23.5%, representing the most common indication for emergency surgery and causing approximately 40% of all ulcer-related deaths 1, 3
• Gastric outlet obstruction - occurs in 3% of complicated cases, though chronic fibrotic disease causing obstruction has become rare with improved medical management 1, 3

Mortality

Annually, approximately 10,000 people die of peptic ulcer disease in the United States. 3 Perforation carries particularly high mortality, with rates up to 30% if treatment is delayed, and every hour of delay from admission to surgery is associated with a 2.4% decreased probability of survival. 7

Diagnosis

Endoscopy is the gold standard for definitive diagnosis of peptic ulcer disease. 4, 5 Endoscopy allows for:

• Direct visualization of ulcers and confirmation of their presence, location, and characteristics 8
• Tissue sampling for histopathology 8
• Simultaneous H. pylori testing from biopsy samples 8
• Exclusion of other serious conditions including malignancy 8

For younger patients without alarm symptoms, a test-and-treat strategy based on noninvasive H. pylori testing can be employed. 5, 6

Treatment Principles

• Acid suppression with proton pump inhibitors (such as omeprazole or lansoprazole) is the primary treatment, healing 80-100% of peptic ulcers within 4 weeks, though gastric ulcers larger than 2 cm may require 8 weeks 3
• H. pylori eradication decreases ulcer recurrence rates from 50-60% to 0-2% 3
• NSAID discontinuation heals 95% of ulcers and reduces recurrence from 40% to 9% 3