• Clinical science

Peptic ulcer disease (PUD)

Abstract

Peptic ulcer disease (PUD) refers to the presence of one or more ulcerative lesions in the stomach or lining of the duodenum. Possible etiologies include infection with the bacterium Helicobacter pylori (most common), prolonged use of nonsteroidal anti-inflammatory medicines (possibly in combination with glucocorticoids), conditions associated with an overproduction of stomach acid (hypersecretory states), and stress. Epigastric pain is a typical symptom of PUD, however, some patients may remain asymptomatic until complications such as bleeding and perforation occur. Diagnosis occurs via direct visualization of the ulcer on esophagogastroduodenoscopy (EGD) and H. pylori detection (via biopsy or non-invasive testing). The first-line treatment for most peptic ulcers involves H. pylori eradication via triple therapy (a course of two different antibiotics in combination with a proton-pump inhibitor) and the withdrawal of offending agents. Antisecretory drugs (e.g., proton-pump inhibitors, or PPIs), which reduce stomach acid production, are continued for 4–8 weeks after eradication therapy and may be considered for maintenance therapy if symptoms recur. Surgical intervention may be necessary in rare cases, especially if complications such as perforation or massive bleeding occur. Stomach cancer is an important differential diagnosis and must be ruled out if risk factors are present.

Epidemiology

References:[1][2][3][4][5]

Epidemiological data refers to the US, unless otherwise specified.

Etiology

References:[2][6][7][8][9][10][11]

Classification

An atypical location is suspicious for carcinoma!
References:[12]

Pathophysiology

Clinical features

Gastric ulcer

Duodenal ulcer

Findings common to both

  • Dyspepsia: postprandial heaviness, early satiety, and gnawing, aching or burning epigastric pain
  • Pain relief with antacids
  • Potential signs of internal bleeding (anemia, hematemesis, melena)
  • ∼ 70% of patients with PUD are asymptomatic
  • Stool sample positive for occult blood (see gastrointestinal bleeding)
Pain and eating
  • Pain increases shortly after eating → weight loss
  • Pain increases 2–5 hours after eating
  • Pain on an empty stomach (hunger pain) that is relieved with food intakeweight gain
Nocturnal pain
  • 30–40% of patients
  • 50–80% of patients

Taking NSAIDs can often mask PUD symptoms until complications such as hemorrhage and perforation occur!

References:[13][14][15][16]

Subtypes and variants

  • Dieulafoy's lesion
    • Description: In this rare disease, minor mucosal trauma can lead to major bleeding. It is caused by an abnormal submucosal artery.
    • Location: proximal stomach
    • Clinical presentation: signs of acute upper GI bleeding
    • Treatment: endoscopic hemostasis (injection therapy, hemoclips, etc.), excision of the susceptible mucosa

References:[17][18][19]

Diagnostics

Diagnostic approach

Testing for Helicobacter pylori

Esophagogastroduodenoscopy (EGD)

  • Most accurate test
  • Patients > 55 years of age or presence of ≥ 1 alarm features, which include:
    • Certain symptoms: dysphagia, painful swallowing, and/or persistent vomiting
    • Signs of active GI bleeding (e.g., melena, anemia)
    • Unintended weight loss
    • A palpable mass, lymphadenopathy
    • Family history of upper GI malignancy in a first-degree relative
  • Biopsy samples from:
  • If active bleeding, EGD can be performed for diagnosis and subsequent hemostasis treatment (electrocautery) in the same session.

To rule out gastric cancer, patients with stomach ulcers should undergo follow-up EGD and histology until the ulcer has healed completely!
References:[16][20][21][22][23]

Treatment

General management of dyspepsia

  • H. pylori positive → eradication therapy (with antibiotics and a PPI) and supportive treatment → continue PPIs for 4–8 weeks → follow-up
  • H. pylori negative → medical acid suppression (with a PPI) and supportive treatment for 4–8 weeks → follow-up

Medical treatment

Supportive treatment

  • Discontinue NSAIDs
  • Restrict alcohol use/smoking/emotional stress
  • Avoid eating before bedtime

Surgical treatment

  • With the advent of potent acid suppression in the form of PPIs, surgical intervention is rarely needed.
  • Indications
    • Refractory syndromes despite appropriate medical treatment
    • If cancer is suspected
    • Complications that cannot be treated endoscopically (see “Complications” below)
  • Partial gastrectomy (Billroth)
    • Billroth I: distal gastrectomy with end-to-end or side-to-end gastroduodenostomy
    • Billroth II: resection of the distal ⅔ of the stomach with a blind ending duodenal stump and end-to-side gastro-jejunostomy. The Billroth I and II methods without a Brown's anastomosis often lead to bile reflux into the stomach. This may result in type C gastritis in the region of the anastomosis. The chronic inflammation causes atrophic changes and increases the risk of cancer (anastomosis carcinoma).
  • Vagotomy

References:[14][20][24][25]

Complications

References:[25][26][27][28][29][30][31][32][33][34]

We list the most important complications. The selection is not exhaustive.

Follow-up

Endoscopic surveillance with biopsies

  • Gastric ulcer: performed after 8–12 weeks of antisecretory treatment in patients with one or more of the following criteria:
    • Refractory symptoms
    • Ulcer of unknown etiology
    • Malignant-appearing ulcer in initial EGD (even if biopsies are negative)
    • No biopsies taken on initial EGD (e.g., due to active bleeding)
    • Ulcer diagnosed via radiologic imaging
  • Duodenal ulcer: indicated if symptoms persist after an appropriate course of antisecretory treatment
  • Bleeding peptic ulcer: endoscopic control on the following day

H. pylori eradication confirmation

  • Performed 4 weeks or more after H. pylori eradication therapy
  • Indication: H. pylori-associated ulcer
  • Diagnostic tests
    • Endoscopic biopsies with rapid urea testing (only if endoscopy is indicated to rule out malignancy; see indications above)
    • Urea breath testing
    • Stool antigen assay

Prevention

Recurrence prophylaxis

Stress ulcer prophylaxis

  • PPIs or H2-blockers
  • Indicated in severe organic disease/stress → shock, acidosis, brain trauma, severe burns, major surgery
  • Disadvantage of prolonged PPI intake: potentially higher risk of pneumonia and gastroenteritis!

References:[35]