Peptic ulcer disease
Definition
Peptic ulcer disease (PUD) is a focal break in the gastric or duodenal mucosa that extends into the submucosa. By convention an ulcer is ≥ 5 mm and penetrates beyond the muscularis mucosae; smaller or more superficial defects are classed as erosions.
Pathophysiology
Ulcers occur when mucosal defence and repair are overwhelmed by injurious factors. Important injurious factors include gastric acid and pepsin, Helicobacter pylori infection, and non‑steroidal anti‑inflammatory drugs (NSAIDs, including aspirin). Other contributors include smoking, excessive alcohol, systemic stress (e.g.
burns), corticosteroids (especially with NSAIDs), and rarer causes such as Crohn’s disease, gastrinoma (Zollinger-Ellison syndrome), and malignancy. Protective mechanisms include the mucus-bicarbonate layer, epithelial restitution, mucosal blood flow and prostaglandin‑mediated maintenance of integrity.
Management is directed at removing causative factors and promoting mucosal protection, commonly with proton pump inhibitors (PPIs).
Epidemiology and aetiology
- Helicobacter pylori is the dominant cause and is present in most duodenal ulcers and a large proportion of gastric ulcers.
- NSAIDs and aspirin are the other major and preventable causes of PUD and its complications.
- PUD is the commonest cause of non‑variceal upper gastrointestinal bleeding and a frequent reason for emergency admission with complications such as perforation.
Clinical features
General symptoms include epigastric pain or discomfort, dyspepsia, nausea and early satiety. Presentations may be atypical or silent, particularly in older adults...