Peptic Ulcer Disease

Key Features

Essentials of Diagnosis

• History of dyspepsia in 80–90% with variable relationship to meals

• Ulcer symptoms are characterized by rhythmicity and periodicity

• Ulcer complications without antecedent symptoms occur in 10–20%

• Most nonsteroidal anti-inflammatory drug (NSAID)-induced ulcers are asymptomatic

• Upper endoscopy with gastric biopsy for Helicobacter pylori is diagnostic

• Gastric ulcer biopsy or documentation of complete healing is necessary to exclude gastric malignancy

General Considerations

• Peptic ulcer is a break in the gastric or duodenal mucosa, extending through the muscularis mucosa, and usually > 5 mm in diameter

• In the stomach, benign ulcers are most common

  • In the antrum (60%)

  • At the junction of the antrum and body on the lesser curvature (25%)

• Major causes of peptic ulcer disease

  • NSAIDs

  • Chronic H pylori infection

• Less than 5–10% of ulcers are caused by other conditions, including

  • Acid hypersecretory states such as Zollinger-Ellison syndrome or systemic mastocytosis

  • Cytomegalovirus (especially in transplant recipients)

  • Crohn disease

  • Lymphoma

  • Medications (eg, alendronate)

  • Chronic medical illness (cirrhosis or chronic kidney disease)

• Up to 10% of ulcers are idiopathic

• In duodenal ulcer patients, prevalence of H pylori infection is ~70–90%; however, ulcers develop in only about 10% of infected persons

• In persons who take NSAIDs long-term, prevalence of gastric ulcers is 10–20% and duodenal ulcers is 2–5%

• H pylori infection increases risk of NSAID-induced ulcers and complications

Demographics

• In the United States, ~500,000 new ulcer cases and 4 million ulcer recurrences per year

• Incidence of duodenal ulcer disease has been declining dramatically for the past 30 years (due to the eradication of H pylori)

• However, the incidence of gastric ulcers has not been declining (due to the widespread use of NSAIDs and low-dose aspirin)

• Lifetime prevalence of ulcers in adults is ~10%

• Duodenal ulcers are most common between the ages of 30 and 55

• Gastric ulcers are most common between the ages of 55 and 70

Clinical Findings

Symptoms and Signs

• Epigastric pain (dyspepsia)

  • Present in 80–90% of persons, but such pain is not sensitive or specific enough to serve as a reliable diagnostic criterion

  • Typically well localized to epigastrium and not severe

  • Described as gnawing, dull, aching, or "hunger-like"

  • Relieved by food or antacids in about 50%

• Ulcer complications, such as bleeding, occur in 20% with no antecedent symptoms ("silent ulcers")

• Nocturnal pain awakens two-thirds of patients with duodenal ulcers and one-third of patients with gastric ulcers

• Most patients have symptomatic periods lasting several weeks with intervals of months to years in which they are pain free (periodicity)

• Nausea and anorexia

• Significant vomiting and weight loss suggest gastric outlet obstruction or gastric malignancy

• Physical examination often normal

• Mild, localized epigastric tenderness to deep palpation

Differential Diagnosis