Peptic ulcer disease

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Hi there!

You’re looking at a short reference article from Explain Medicine (one of four distinct learning formats available in Clinical Odyssey). Try it out, and have fun improving your clinical skills.

Medicine

Last updated on:
June 25^th, 2021

Medicine

Last updated on:
June 25^th, 2021

Hi there!

You’re looking at a short reference article from Explain Medicine (one of four distinct learning formats available in Clinical Odyssey). Try it out, and have fun improving your clinical skills.

Clinicals - History

Fact	Explanation
Introduction	A peptic ulcer is an ulcer in the lining of the stomach or duodenum that is caused by exposure to gastric acid.
Dyspepsia	Dyspepsia will usually have been present for at least one month. Dyspepsia is characterized by gnawing or burning epigastric pain that occurs two to five hours after meals, or on an empty stomach; and which may awaken the patient at night. Dyspepsia is relieved by food intake, antacids, or antisecretory agents—all of these counterbalance acid secretion by the stomach. Persistent pain may suggest complications such as bleeding, obstruction, or perforation.
Epigastric fullness	Epigastric fullness indicates abnormal gastric emptying. This is typically due to dysfunction of gastric motor function; mucosal inflammation, irritation, and spasm may contribute.
Nausea and vomiting	Nausea and vomiting may occur—particularly if there is gastric outlet obstruction.
Heartburn	Heartburn may occur if there is co-existing gastroesophageal reflux. This is due to irritation of the esophageal mucosa by contact with the acidic gastric contents.
Anorexia and weight loss	Anorexia and weight loss may be caused by fear of food intake; or where malignant transformation has occurred, due to gastric cancer.
Hematemesis and melena	Hematemesis and melena may occur following acute or subacute bleeding of a peptic ulcer.
No symptoms	Nearly one-third of older patients with peptic ulcers do not have abdominal pain or show only mild pain.
Helicobacter pylori infection	Helicobacter pylori infection is the major cause of PUD. All patients should be explicitly asked as to whether they were tested in the past in this regard; and if they tested positive, whether a full course of treatment was completed.
Other comorbidities	Risk factors for PUD include a past history of PUD, cirrhosis, chronic kidney disease, Crohn’s disease, sarcoidosis, gastric cancer, lung cancer, lymphomas, myeloproliferative disorders, tuberculosis, cytomegalovirus infection, critical illness, and rarely, hypersecretory states such as Zollinger-Ellison syndrome.
Nonsteroidal Anti-Inflammatory Drug (NSAID) use	NSAID use is the second most common cause of peptic ulcer disease. NSAIDs inhibit cyclo-oxygenase-1 (COX-1), an enzyme present in gastrointestinal epithelium that regulates prostaglandin secretion. Prostaglandins are mediators in mucosal protection; a decrease in their levels increases the risk of mucosal disruption and ulceration. Concomitant inhibition of cyclo-oxygenase-2 (COX-2), an isoenzyme induced by inflammation, may also play a role.
Other drugs	A detailed medication history should be obtained—especially in the elderly. Drugs to look for include antiplatelet drugs, warfarin, selective serotonin reuptake inhibitors, bisphosphonates, corticosteroids, potassium chloride and chemotherapeutic agents.
Social history	There is limited evidence of an association between PUD and alcohol, illegal drug use, stress, and social deprivation. Smoking appears to confer an increased risk of duodenal ulcers, in patients with Helicobacter pylori infection.

Introduction

A peptic ulcer is an ulcer in the lining of the stomach or duodenum that is caused by exposure to gastric acid.

Dyspepsia

Dyspepsia will usually have been present for at least one month. Dyspepsia is characterized by gnawing or burning epigastric pain that occurs two to five hours after meals, or on an empty stomach; and which may awaken the patient at night. Dyspepsia is relieved by food intake, antacids, or antisecretory agents—all of these counterbalance acid secretion by the stomach. Persistent pain may suggest complications such as bleeding, obstruction, or perforation.

Epigastric fullness

Epigastric fullness indicates abnormal gastric emptying. This is typically due to dysfunction of gastric motor function; mucosal inflammation, irritation, and spasm may contribute.

Nausea and vomiting

Nausea and vomiting may occur—particularly if there is gastric outlet obstruction.

Heartburn

Heartburn may occur if there is co-existing gastroesophageal reflux. This is due to irritation of the esophageal mucosa by contact with the acidic gastric contents.

Anorexia and weight loss

Anorexia and weight loss may be caused by fear of food intake; or where malignant transformation has occurred, due to gastric cancer.

Hematemesis and melena

Hematemesis and melena may occur following acute or subacute bleeding of a peptic ulcer.

No symptoms

Nearly one-third of older patients with peptic ulcers do not have abdominal pain or show only mild pain.

Helicobacter pylori infection

Helicobacter pylori infection is the major cause of PUD. All patients should be explicitly asked as to whether they were tested in the past in this regard; and if they tested positive, whether a full course of treatment was completed.

Other comorbidities

Risk factors for PUD include a past history of PUD, cirrhosis, chronic kidney disease, Crohn’s disease, sarcoidosis, gastric cancer, lung cancer, lymphomas, myeloproliferative disorders, tuberculosis, cytomegalovirus infection, critical illness, and rarely, hypersecretory states such as Zollinger-Ellison syndrome.

Nonsteroidal Anti-Inflammatory Drug (NSAID) use

NSAID use is the second most common cause of peptic ulcer disease. NSAIDs inhibit cyclo-oxygenase-1 (COX-1), an enzyme present in gastrointestinal epithelium that regulates prostaglandin secretion. Prostaglandins are mediators in mucosal protection; a decrease in their levels increases the risk of mucosal disruption and ulceration. Concomitant inhibition of cyclo-oxygenase-2 (COX-2), an isoenzyme induced by inflammation, may also play a role.

Other drugs

A detailed medication history should be obtained—especially in the elderly. Drugs to look for include antiplatelet drugs, warfarin, selective serotonin reuptake inhibitors, bisphosphonates, corticosteroids, potassium chloride and chemotherapeutic agents.

Social history

There is limited evidence of an association between PUD and alcohol, illegal drug use, stress, and social deprivation. Smoking appears to confer an increased risk of duodenal ulcers, in patients with Helicobacter pylori infection.

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