Peptic ulcer

Content of This Page

 1- Introduction

2- Causes

3- Pathophysiology

4- Signs & Symptoms

5- Types of Peptic Ulcer

6- Risk Factors

7- Investigations & Lab Results

8- Complications

9- Treatment

Introduction

Peptic Ulcer is a break or sore in the mucosal lining of the stomach (gastric ulcer) or the duodenum (duodenal ulcer), caused by an imbalance between aggressive factors like gastric acid and pepsin and defensive mechanisms such as the mucus-bicarbonate barrier, prostaglandins, and adequate blood flow. The most common cause is infection with Helicobacter pylori, a bacterium that damages the mucosal lining and promotes inflammation. Another major cause is the chronic use of nonsteroidal anti-inflammatory drugs (NSAIDs), which inhibit prostaglandin synthesis, reducing mucosal protection. Other contributing factors include smoking, alcohol, stress, and genetic predisposition.

Causes

  • Helicobacter pylori infection

  • NSAIDs (Nonsteroidal Anti-Inflammatory Drugs)

  • Stress (severe illness, burns, trauma)

  • Zollinger-Ellison syndrome (gastrinoma)

  • Smoking

  • Alcohol consumption

  • Excessive caffeine intake

  • Genetic predisposition

  • Hypersecretory states

  • Malignancy (gastric cancer can mimic ulcers)

Pathophysiology

Peptic Ulcer results from an imbalance between aggressive factors and the protective mechanisms of the gastric or duodenal mucosa. Increased aggressive factors such as gastric acid and pepsin cause mucosal damage. Helicobacter pylori infection contributes by damaging the mucosa and increasing acid secretion. NSAIDs impair mucosal defenses by inhibiting prostaglandin synthesis, which reduces mucus and bicarbonate production. Smoking and alcohol further decrease mucosal blood flow and impair healing. At the same time, a reduction in protective factors like mucus secretion, bicarbonate, mucosal blood flow, epithelial regeneration, and prostaglandins leads to weakened mucosal defense. This imbalance ultimately results in mucosal injury and ulcer formation. In Zollinger-Ellison syndrome, excessive acid secretion caused by a gastrin-secreting tumor leads to multiple and difficult-to-treat ulcers.

Signs & Symptoms

  • Epigastric pain (burning or gnawing)

  • Pain related to meals:

    • Duodenal ulcer: pain relieved by eating, recurs 2–3 hours after meals

    • Gastric ulcer: pain worsens with eating

  • Dyspepsia (indigestion)

  • Nausea and vomiting

  • Bloating and early satiety

  • Weight loss (especially in gastric ulcers)

  • Hematemesis or melena (if bleeding occurs)

  • Signs of perforation (acute severe abdominal pain, rigidity)

  • Anemia symptoms (fatigue, pallor) if chronic bleeding

Types of Peptic Ulcer

FeatureGastric UlcerDuodenal Ulcer
LocationStomach (usually antrum)First part of duodenum
Pain relation to foodWorsens with eatingRelieved by eating
Age groupOlder adultsYounger adults
Acid secretionNormal or decreasedIncreased
Malignancy riskHigher risk (needs biopsy)Rarely malignant
Weight changesWeight lossnormal
NSAIDs associationStrong associationLess association
Common causeH. pylori, NSAIDsH. pylori
Bleeding riskModerateHigher risk

Risk Factors

  • Helicobacter pylori infection

  • Regular or prolonged use of NSAIDs (aspirin, ibuprofen, etc.)

  • Smoking tobacco

  • Excessive alcohol consumption

  • High stress levels (especially severe physical stress like trauma or surgery)

  • Older age (mucosal defenses weaken with age)

  • Family history of peptic ulcers

  • Certain medical conditions (e.g., Zollinger-Ellison syndrome)

  • Use of corticosteroids or anticoagulants (which can increase bleeding risk)

  • Poor diet or irregular eating habits (less directly, but may worsen symptoms)

Investigations & Lab Results

-Endoscopy (Gold Standard)

  • Direct visualization of ulcer

  • Location, size, depth assessment

  • Biopsy to rule out malignancy (especially in gastric ulcers)

  • Rapid urease test for H. pylori detection

-H. pylori Testing

  • Urea breath test (non-invasive, highly sensitive)

  • Stool antigen test (non-invasive, reliable)

  • Serology for H. pylori antibodies (less preferred, can’t differentiate past vs. current infection)

  • Biopsy with histology (via endoscopy)

-Blood Tests

  • Complete blood count (CBC) – may show anemia if bleeding

  • Iron studies – may show iron deficiency anemia

  • Liver and renal function tests – to rule out other causes or pre-endoscopy check

  • Serum gastrin levels – elevated in Zollinger-Ellison syndrome

-Imaging (if perforation or obstruction suspected)

  • Abdominal X-ray – free air under diaphragm (perforation)

  • CT scan of abdomen – complications like perforation, penetration, or obstruction

  • Barium meal X-ray (less commonly used now) – shows ulcer crater or deformity

-Stool Occult Blood Test

  • Detects gastrointestinal bleeding (positive if ulcer is bleeding)

Complications

  • Bleeding (most common complication; can cause hematemesis or melena)

  • Perforation (sudden severe abdominal pain, peritonitis)

  • Penetration (ulcer extends into adjacent organs like pancreas)

  • Gastric outlet obstruction (due to edema or scarring)

  • Malignancy (especially in gastric ulcers)

  • Intractable pain

  • Fistula formation (rare)

 

Complications

  • Eradication of H. pylori

    • Triple therapy: PPI + Clarithromycin + Amoxicillin/Metronidazole

    • Quadruple therapy (if resistance or failure): PPI + Bismuth + Metronidazole + Tetracycline

  • Acid Suppression

    • Proton Pump Inhibitors (PPIs) – mainstay (e.g., omeprazole, pantoprazole)

    • H2 receptor blockers – alternative (e.g., ranitidine, famotidine)

  • Stop NSAIDs

    • Discontinue NSAIDs if possible

    • Use PPIs if NSAIDs are necessary

  • Lifestyle Modifications

    • Smoking cessation

    • Avoid alcohol

    • Avoid caffeine and spicy foods

    • Stress management

  • Treatment of Complications

    • Bleeding: endoscopic hemostasis, PPI infusion, surgery if uncontrolled

    • Perforation: emergency surgery

    • Obstruction: endoscopic dilation or surgery

    • Penetration: manage surgically if severe

  • Surgery (rarely needed today)

    • For refractory ulcers, complications, or suspected malignancy

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