- Peptic ulcers are open sores that develop on the inner lining of the stomach (gastric ulcers), the first part of the small intestine (duodenal ulcers), or, rarely, the lower esophagus. These ulcers result from the erosion of the mucosal lining due to an imbalance between aggressive factors like gastric acid and pepsin and the protective mechanisms of the mucosa.
- Peptic ulcer disease (PUD) remains a significant health issue worldwide, especially in regions with a high prevalence of Helicobacter pylori infection. While most ulcers are treatable, their complications can be life-threatening if not promptly addressed.
- The two most common causes of peptic ulcers are H. pylori infection and the use of nonsteroidal anti-inflammatory drugs (NSAIDs).
- H. pylori colonizes the gastric epithelium and induces chronic inflammation, damaging the mucosal lining and making it susceptible to acid-related injury. NSAIDs, on the other hand, interfere with prostaglandin synthesis, reducing mucus and bicarbonate production and impairing mucosal blood flow.
- Other risk factors include smoking, excessive alcohol consumption, stress in critically ill patients (stress ulcers), and rare conditions such as Zollinger-Ellison syndrome, which causes excessive gastric acid secretion due to a gastrin-producing tumor.
- The stomach and duodenal lining are protected by a complex system involving mucus secretion, bicarbonate buffering, prostaglandins, and epithelial cell renewal. Disruption of this balance—either through excessive acid production or compromised mucosal defense—leads to ulceration.
- In H. pylori-associated ulcers, bacterial enzymes like urease and virulence factors such as CagA and VacA damage epithelial cells and provoke inflammation.
- NSAID-induced ulcers typically develop in the gastric mucosa and are often asymptomatic until complications occur, due to the suppression of protective prostaglandins.
- Symptoms of peptic ulcers can vary depending on their location and severity.
- The most common complaint is epigastric pain—described as burning, gnawing, or aching—that may be relieved or exacerbated by food.
- Duodenal ulcers typically cause pain a few hours after eating and may improve with food or antacids, whereas gastric ulcer pain often worsens with meals.
- Other symptoms include bloating, nausea, early satiety, and in some cases, vomiting.
- More severe cases can present with complications such as gastrointestinal bleeding (manifested as melena or hematemesis), perforation, or gastric outlet obstruction.
- The gold standard for diagnosing peptic ulcers is upper gastrointestinal endoscopy, which allows direct visualization and biopsy of the ulcer. Gastric ulcers, in particular, should always be biopsied to rule out malignancy.
- Non-invasive testing for H. pylori includes the urea breath test, stool antigen test, and serology (although serology cannot distinguish active from past infection).
- Laboratory investigations may show anemia in cases of chronic blood loss. Imaging, such as an abdominal X-ray or CT scan, is reserved for complications like perforation.
- Management depends on the underlying cause of the ulcer.
- For H. pylori-positive ulcers, eradication therapy typically includes a proton pump inhibitor (PPI) combined with two or more antibiotics, such as amoxicillin, clarithromycin, or metronidazole, for 10–14 days. Successful eradication significantly reduces the risk of recurrence.
- NSAID-induced ulcers require discontinuation of the offending drug, if possible, and acid suppression therapy using PPIs. For patients who must continue NSAID therapy, co-prescription of PPIs or switching to COX-2 inhibitors can help reduce ulcer risk.
- Maintenance therapy may be necessary in patients with recurrent ulcers or those who cannot eliminate the precipitating factor.
- If left untreated, peptic ulcers can lead to serious complications.
- Gastrointestinal bleeding is the most common and may present with melena, hematemesis, or iron-deficiency anemia.
- Perforation, a life-threatening emergency, causes sudden, severe abdominal pain and peritonitis.
- Gastric outlet obstruction can result from chronic inflammation and scarring, leading to nausea, vomiting, and weight loss.
- Chronic gastric ulcers, especially if associated with H. pylori and intestinal metaplasia, carry a risk of malignant transformation, highlighting the importance of endoscopic surveillance and biopsy.
- The prognosis for peptic ulcer disease is generally excellent with appropriate medical management.
- Eradication of H. pylori and avoidance of NSAIDs are key to long-term resolution.
- Preventive strategies include limiting NSAID use, using PPIs when NSAIDs are necessary, avoiding tobacco and excessive alcohol, and managing underlying medical conditions.
- In high-risk patients, such as those with prior ulcers or cardiovascular disease requiring antiplatelet therapy, gastroprotective agents should be co-administered.
- Peptic ulcers are a common but largely preventable gastrointestinal disorder. With a thorough understanding of their etiology and pathophysiology, clinicians can offer effective diagnostic and therapeutic approaches.
- Modern treatment, especially with H. pylori eradication and acid suppression, has greatly reduced the morbidity and mortality associated with this condition. Continued public health efforts and clinical vigilance are essential in preventing ulcer-related complications and ensuring optimal outcomes for affected individuals.
