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For further information, see CMDT Part 15-23: Peptic Ulcer Disease
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Essentials of Diagnosis
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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
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General Considerations
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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
Major causes of peptic ulcer disease
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
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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
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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
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Differential Diagnosis
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