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A 41-year-old man presents with a 4-month history of epigastric pain. The pain is dull, achy, and intermittent; there is no radiation of the pain and it has not changed in character since it began. Coffee intake seems to exacerbate the symptoms, whereas eating or drinking milk helps. Infrequently, he is awakened at night by the pain. He reports no weight loss, vomiting, melena, or hematochezia. On examination, there is mild epigastric tenderness with no rebound or guarding. The remainder of the examination is unremarkable. A stool antigen test is positive for Helicobacter pylori, and the patient is treated for peptic ulcer disease with eradication therapy.


Peptic ulcer disease (PUD) is a disease of the gastrointestinal (GI) tract characterized by a break in the mucosal lining of the stomach or duodenum due to pepsin and gastric acid secretion. This damage is greater than 5 mm in size and with a depth reaching the submucosal layer.1


  • PUD is a common disorder affecting approximately 4.5 million people annually in the United States. It encompasses both gastric and duodenal ulcers (Figures 61-1 and 61-2).2

  • One-year point prevalence is 1.8%, and the lifetime prevalence is 10% in the United States.2

  • Prevalence is similar in both sexes, with increased incidence with age.1 Duodenal ulcers most commonly occur in patients between the ages of 30 and 55 years, whereas gastric ulcers are more common in patients between the ages of 55 and 70 years.2

  • PUD incidence in H. pylori–infected individuals is approximately 1% per year (6- to 10-fold higher than uninfected subjects).1

  • Physician office visits and hospitalizations for PUD have decreased in the past few decades.1

  • The incidence of peptic ulcers is declining, possibly as a result of the increasing use of proton pump inhibitors and eradication of H. pylori infection.


Endoscopic pictures of a gastric ulcer. Plates 1 and 2 show erosions. Note that the bleeding is from biopsy. Plates 3 and 4 show a large crater with evidence of recent bleeding. Both are consistent with severe ulcer disease. (Reproduced with permission from Michael Harper, MD.)


Endoscopic view of a pyloric ulcer and an erosion of the mucosa. The ulcer and erosion are benign peptic ulcer disease and not malignant. (Reproduced with permission from Marvin Derezin, MD.)


  • Causes of PUD include:

    • Nonsteroidal anti-inflammatory drugs (NSAIDs), chronic H. pylori infection, and acid hypersecretory states such as Zollinger-Ellison syndrome.2

    • Uncommon causes include Cytomegalovirus (especially in transplantation recipients), systemic mastocytosis, Crohn disease, lymphoma, and medications (e.g., alendronate).2

    • Up to 10% of ulcers ...

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