Peptic ulcer disease

Peptic ulcer disease
SynonymsPeptic ulcer, stomach ulcer, gastric ulcer, duodenal ulcer
Deep gastric ulcer.png
Deep gastric ulcer
SpecialtyGastroenterology, general surgery
SymptomsUpper abdominal pain, belching, vomiting, weight loss, poor appetite[1]
ComplicationsBleeding, perforation, blockage of the stomach[2]
CausesHelicobacter pylori, non-steroidal anti-inflammatory drugs, tobacco smoking, Crohn disease[1][3]
Diagnostic methodBased on symptoms, confirmed by endoscopy or barium swallow[1]
Differential diagnosisStomach cancer, coronary heart disease, inflammation of the stomach lining, gallbladder inflammation[1]
TreatmentStopping smoking, stopping NSAIDs, stopping alcohol, medications[1]
MedicationProton pump inhibitor, H2 blocker, antibiotics[1][4]
Frequency87.4 million (2015)[5]
Deaths267,500 (2015)[6]

Peptic ulcer disease (PUD) is a break in the inner lining of the stomach, first part of the small intestine or sometimes the lower esophagus.[1][7] An ulcer in the stomach is known as a gastric ulcer while that in the first part of the intestines is known as a duodenal ulcer.[1] The most common symptoms of a duodenal ulcer are waking at night with upper abdominal pain or upper abdominal pain that improves with eating.[1] With a gastric ulcer the pain may worsen with eating.[8] The pain is often described as a burning or dull ache.[1] Other symptoms include belching, vomiting, weight loss, or poor appetite.[1] About a third of older people have no symptoms.[1] Complications may include bleeding, perforation and blockage of the stomach.[2] Bleeding occurs in as many as 15% of people.[2]

Common causes include the bacteria Helicobacter pylori and non-steroidal anti-inflammatory drugs (NSAIDs).[1] Other less common causes include tobacco smoking, stress due to serious illness, Behcet disease, Zollinger-Ellison syndrome, Crohn disease and liver cirrhosis, among others.[1][3] Older people are more sensitive to the ulcer-causing effects of NSAIDs.[1] The diagnosis is typically suspected due to the presenting symptoms with confirmation by either endoscopy or barium swallow.[1] H. pylori can be diagnosed by testing the blood for antibodies, a urea breath test, testing the stool for signs of the bacteria, or a biopsy of the stomach.[1] Other conditions that produce similar symptoms include stomach cancer, coronary heart disease, and inflammation of the stomach lining or gallbladder inflammation.[1]

Diet does not play an important role in either causing or preventing ulcers.[9] Treatment includes stopping smoking, stopping NSAIDs, stopping alcohol and giving medications to decrease stomach acid.[1] The medication used to decrease acid is usually either a proton pump inhibitor (PPI) or an H2 blocker with four weeks of treatment initially recommended.[1] Ulcers due to H. pylori are treated with a combination of medications such as amoxicillin, clarithromycin and a PPI.[4] Antibiotic resistance is increasing and thus treatment may not always be effective.[4] Bleeding ulcers may be treated by endoscopy, with open surgery typically only used in cases in which it is not successful.[2]

Peptic ulcers are present in around 4% of the population.[1] New ulcers were found in around 87.4 million people worldwide during 2015.[5] About 10% of people develop a peptic ulcer at some point in their life.[10] They resulted in 267,500 deaths in 2015 down from 327,000 deaths in 1990.[6][11] The first description of a perforated peptic ulcer was in 1670 in Princess Henrietta of England.[2] H. pylori was first identified as causing peptic ulcers by Barry Marshall and Robin Warren in the late 20th century,[4] a discovery for which they received the Nobel Prize in 2005.[12]

Signs and symptoms

Gastric ulcer
Duodenal ulcer A2 stage, acute duodenal mucosal lesion(ADML)

Signs and symptoms of a peptic ulcer can include one or more of the following:

A history of heartburn, gastroesophageal reflux disease (GERD) and use of certain forms of medication can raise the suspicion for peptic ulcer. Medicines associated with peptic ulcer include NSAIDs (non-steroid anti-inflammatory drugs) that inhibit cyclooxygenase, and most glucocorticoids (e.g. dexamethasone and prednisolone).

In people over the age of 45 with more than two weeks of the above symptoms, the odds for peptic ulceration are high enough to warrant rapid investigation by esophagogastroduodenoscopy.

The timing of the symptoms in relation to the meal may differentiate between gastric and duodenal ulcers: A gastric ulcer would give epigastric pain during the meal, associated with nausea and vomiting, as gastric acid production is increased as food enters the stomach. Pain in duodenal ulcers would be aggravated by hunger, relieved by a meal, and is associated with night pain.[14]

Also, the symptoms of peptic ulcers may vary with the location of the ulcer and the person's age. Furthermore, typical ulcers tend to heal and recur and as a result the pain may occur for few days and weeks and then wane or disappear.[15] Usually, children and the elderly do not develop any symptoms unless complications have arisen.

Burning or gnawing feeling in the stomach area lasting between 30 minutes and 3 hours commonly accompanies ulcers. This pain can be misinterpreted as hunger, indigestion or heartburn. Pain is usually caused by the ulcer but it may be aggravated by the stomach acid when it comes into contact with the ulcerated area. The pain caused by peptic ulcers can be felt anywhere from the navel up to the sternum, it may last from few minutes to several hours and it may be worse when the stomach is empty. Also, sometimes the pain may flare at night and it can commonly be temporarily relieved by eating foods that buffer stomach acid or by taking anti-acid medication.[16] However, peptic ulcer disease symptoms may be different for every sufferer.[17]

Complications

  • Gastrointestinal bleeding is the most common complication. Sudden large bleeding can be life-threatening.[18] It is associated with 5% to 10% death rate.[14]
  • Perforation (a hole in the wall of the gastrointestinal tract) often leads to catastrophic consequences if left untreated. Erosion of the gastro-intestinal wall by the ulcer leads to spillage of the stomach or intestinal content into the abdominal cavity. Perforation at the anterior surface of the stomach leads to acute peritonitis, initially chemical and later bacterial peritonitis.[citation needed] The first sign is often sudden intense abdominal pain[14] such as Valentino's syndrome. Posterior wall perforation leads to bleeding due to the involvement of gastroduodenal artery that lies posterior to the first part of the duodenum.[citation needed] The death rate in this case is 20%.[14]
  • Penetration is a form of perforation in which the hole leads to and the ulcer continues into adjacent organs such as the liver and pancreas.[15]
  • Gastric outlet obstruction is a narrowing of the pyloric canal by scarring and swelling of the gastric antrum and duodenum due to peptic ulcers. The person often presents with severe vomiting.[14]
  • Cancer is included in the differential diagnosis (elucidated by biopsy), Helicobacter pylori as the etiological factor making it 3 to 6 times more likely to develop stomach cancer from the ulcer.[15]
Other Languages
Afrikaans: Maagsweer
العربية: قرحة هضمية
azərbaycanca: Mədə xorası
تۆرکجه: معده خوراسی
беларуская (тарашкевіца)‎: Язвавая хвароба
български: Язва
bosanski: Peptični ulkus
dansk: Mavesår
davvisámegiella: Čoavjehávvi
ދިވެހިބަސް: ގޮހޮރުގެ ފާރު
Ελληνικά: Έλκος
فارسی: زخم معده
한국어: 위궤양
hrvatski: Peptički ulkus
Bahasa Indonesia: Ulkus peptikum
italiano: Ulcera peptica
עברית: כיב פפטי
македонски: Чир на желудникот
Bahasa Melayu: Ulser peptik
Nederlands: Maagzweer
日本語: 消化性潰瘍
norsk: Magesår
norsk nynorsk: Magesår
ଓଡ଼ିଆ: ଅମ୍ଳରୋଗ
oʻzbekcha/ўзбекча: Yara kasalligi
português: Úlcera péptica
русский: Язва желудка
саха тыла: Куртах бааһа
Simple English: Peptic ulcer
slovenčina: Peptický vred
slovenščina: Peptična razjeda
srpskohrvatski / српскохрватски: Čir na dvanaestopalačnom crevu
suomi: Mahahaava
svenska: Magsår
Türkçe: Peptik ülser
українська: Пептична виразка