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PEPTIC ULCER DISEASE (PUD)

PUD occurs most commonly in duodenal bulb (duodenal ulcer, DU) and stomach (gastric ulcer, GU). It may also occur in esophagus, pyloric channel, duodenal loop, jejunum, Meckel's diverticulum. PUD results when "aggressive" factors (gastric acid, pepsin) overwhelm "defensive" factors involved in mucosal resistance (gastric mucus, bicarbonate, microcirculation, prostaglandins, mucosal "barrier"), and from effects of Helicobacter pylori.

CAUSES AND RISK FACTORS

General

H. pylori is a spiral urease-producing organism that colonizes gastric antral mucosa in up to 100% of persons with DU and 80% with GU. It is also found in normals (increasing prevalence with age) and in those of low socioeconomic status. H. pylori is invariably associated with histologic evidence of active chronic gastritis, which over years can lead to atrophic gastritis and gastric cancer. The other major cause of ulcers (those not due to H. pylori) is nonsteroidal anti-inflammatory drugs (NSAIDs). Fewer than 1% are due to gastrinoma (Zollinger-Ellison syndrome). Other risk factors and associations: hereditary (? increased parietal cell number), smoking, hypercalcemia, mastocytosis, blood group O (antigens may bind H. pylori). Unproven: stress, coffee, alcohol.

Duodenal Ulcer

Mild gastric acid hypersecretion resulting from (1) increased release of gastrin, presumably due to (a) stimulation of antral G cells by cytokines released by inflammatory cells and (b) diminished production of somatostatin by D cells, both resulting from H. pylori infection; and (2) an exaggerated acid response to gastrin due to an increased parietal cell mass resulting from gastrin stimulation. These abnormalities reverse rapidly with eradication of H. pylori. However, a mildly elevated maximum gastric acid output in response to exogenous gastrin persists in some pts long after eradication of H. pylori, suggesting that gastric acid hypersecretion may be, in part, genetically determined. H. pylori may also result in elevated serum pepsinogen levels. Mucosal defense in duodenum is compromised by toxic effects of H. pylori infection on patches of gastric metaplasia that result from gastric acid hypersecretion or rapid gastric emptying. Other risk factors include glucocorticoids, NSAIDs, chronic renal failure, renal transplantation, cirrhosis, chronic lung disease.

Gastric Ulcer

H. pylori is also principal cause. Gastric acid secretory rates are usually normal or reduced, possibly reflecting earlier age of infection by H. pylori than in DU pts. Gastritis due to reflux of duodenal contents (including bile) may play a role. Chronic salicylate or NSAID use may account for 15–30% of GUs and increase risk of associated bleeding, perforation.

CLINICAL FEATURES

Duodenal Ulcer

Burning epigastric pain 90 min to 3 h after meals, often nocturnal, relieved by food.

Gastric Ulcer

Burning epigastric pain made worse by or unrelated to food; anorexia, food aversion, weight loss (in 40%). Great individual variation. Similar symptoms may occur ...

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