Last updated on:June 25th, 2021
A peptic ulcer is an ulcer in the lining of the stomach or duodenum that is caused by exposure to gastric acid.
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 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 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.
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.
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.
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.
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.