2. Introduction
• Peptic ulcer disease (PUD) refers to ulceration of the mucosa anywhere in
the GI tract due to exposure to acid and pepsin.
• Erosion of GI mucosa resulting from digestive action of HCl and pepsin.
• Lesion may subsequently occur into the lamina propria and submucosa to
cause bleeding.
• Most of peptic ulcer occur either in the duodenum, or in the stomach.
• Ulcer may also occur in the lower esophagus due to reflexing of gastric
content.
• They can range in size from a few millimeters to a few centimeters
• The 2 most common forms/locations of PUD are
– Duodenal ulcer
– Gastric ulcer
3. Duodenal Ulcers
It is the most common form of PUD.
3 times more common than gastric ulcer.
Usually located in duodenal bulb of the small intestine.
Most commonly occurs in people between the age of 30
and 50 years.
4. Gastric Ulcers
Less common than duodenal ulcer.
Especially in the absence of chronic use of NSAIDS
Most commonly located in the lesser curvature of the
antrum of the stomach.
More common in people greater than 60 years.
5. Risk factors for PUD
• Lifestyle
– Smoking, Acidic drinks, Medications (eg. NSAIDS,
Steroid therapy).
• H. Pylori infection – 90% have this bacterium – Passed
from person to person (fecal-oral route or oral-oral
route).
• Age – Duodenal 30-40 – Gastric over 50years.
• Gender – Duodenal: are increasing in older women.
• Genetic factors – More likely if family member has Hx of
PUD.
• Other factors: stress, can worsen (but not the cause).
7. Zollinger-Ellison Syndrome (ZES)
• ZES is characterized by gastric acid hypersecretion
and recurrent peptic ulcers that result from a
gastrin-producing tumor
– More than 50% of gastrinomas are malignant
• ZES is suspected for patients with multiple ulcers
and recurrent or refractory PUD often accompanied
by esophagitis or ulcer complications
• Only accounts for 0.1% to 1% of those with duodenal
ulcer
8. Pathophysiology
Under normal conditions, a physiologic balance
exists between gastric acid secretion and
gastroduodenal mucosal defense.
Gastric and duodenal ulcers develop because of an
imbalance between aggressive factors and mechanisms
that maintain mucosal integrity.
There is an increase in mucosal injury and a decrease in
mucosal defense.
Aggressive factors (H. pylori, NSAIDs) cause mucosal
injury and a decrease in mucosal defenses and healing
(decreased mucous, decreased bicarbonate, decreased
mucosal blood flow)
9. Signs and Symptoms
Symptoms depend on ulcer location, ulcer etiology, and
patient age
Many patients, particularly the elderly, have few or
even no symptoms
NSAID-induced ulcers are often silent
Complications such as bleeding and perforation are often
the initial presentation
10. • Pain localized to the epigastrium is the most
common symptom.
• The pain is described as burning, gnawing, cramping,
or hunger.
• A typical nocturnal pain that wakes the patient from
sleep (especially between 12 and 3am).
• The severity of ulcer pain varies from patient to
patient and my be seasonal, occurring more often in
the spring or fall.
11. Episodes of pain usually occur in clusters, lasting up to a
few weeks followed by a pain-free period or remission
lasting weeks to years.
Changes in the character of pain may suggest the
presence of complications.
Pyrosis (heartburn), belching, and bloating may
accompany the pain.
12. Complications
Major complications of PUD include:
Bleeding
Occurs in about 15% of patients with active PUD
Perforation
Occurs in about 7% of patients with active PUD
Mortality
Mortality from acute bleeding is about 6% - 10%
13. Diagnostic Studies
• Endoscopy procedure
– Determines degree of ulcer healing after treatment
– Tissue specimens can be obtained to identify H. pylori and to rule out
gastric cancer
• Tests for H.pylori
– Noninvasive tests
• Serum or whole blood antibody tests
– Immunoglobin G (I g G)
• Urea breath test
• C 14 breath test
– Invasive tests
• Biopsy of stomach
• Rapid urease test
14. Barium contrast studies
Widely used
X- ray studies
Ineffective in differentiating a peptic ulcer from a
malignant tumor
Gastric analysis
Lab analysis
