Peptic ulcer disease

Peptic ulcer disease affects 1-2 per 1000 people annually (Sverdén et al, 2019). The incidence is 0.1-3% per year but it varies with age and gender (Lanas et al 2017; National Institute for Health and Care Excellence (NICE), 2019).

Overall, the incidence is declining, possibly due to decreasing prevalence of Helicobacter pylori (H. pylori) infection. Generally, the incidence increases with age in patients who have more comorbidities and who frequently use more ulcerogenic medications.

Traditionally, a hypersecretory acidic environment together with dietary factors or stress were thought to cause the most peptic ulcer diseases, however the discovery of H. pylori infection and the widespread use of non-steroidal anti-inflammatory drugs (NSAIDs) in the second half of the 20th century have changed this perception.

More than 90% of duodenal ulcers and more than 70-80% of gastric ulcers are linked to H. pylori infection; eradication therapy with antibiotics and proton pump inhibitors is

Peptic ulcer disease is often defined as a mucosal break greater than 3-5 mm in the epithelium of the stomach and/or the duodenum mucosa with a visible depth reaching the submucosa (Sverden et al, 2019). Peptic ulcer disease results from an imbalance between factors that protect the mucosa of the stomach and duodenum (such as bicarbonate, blood flow, prostaglandins, mucus), and factors that cause damage to it (H. pylori, gastric acid, pepsin and non-steroid anti-inflammatory drugs (NSAIDs), (Sverdén et al, 2019).

H. pylori and the use of NSAIDs or aspirin are the main risk factors of both gastric and duodenal ulcers. However, only a few people with H. pylori infection or taking NSAIDs or aspirin develop peptic ulcer disease, suggesting that individual susceptibility to bacterial virulence and drug toxicity is essential to the initiation of mucosal damage (Narayanan et all 2018). H. pylori is also an important risk factor for gastric cancer, which further emphasises the importance of its eradication (Sverdén et al, 2019). Additional drugs (such as bisphosphonate, corticosteroid, potassium supplements, selective serotonin reuptake inhibitors and recreational drugs) have been associated with peptic ulcers diseases (NICE, 2019).

Zollinger Ellison syndrome, although rare, may be associated with multiple peptic ulcers (NICE, 2019). Marginal ulcers are seen in approximately 5% of patients who have undergone gastric bypass surgery for obesity (Dittrich et al, 2020). Physiological stress associated with trauma or critical illness

Sign and symptoms of peptic ulcer disease are non-specific. Patients with duodenal ulcers may feel hungry or have nocturnal abdominal pain, while patients with gastric ulcers may have postprandial abdominal pain, nausea, vomiting, and weight loss (Narayanan et al, 2018). Some people may experience other symptoms such as indigestion, heart burn, acid reflux and feeling sick (NICE, 2019). Elderly patients with peptic ulcer disease are frequently asymptomatic or have only mild symptoms. Bleeding, perforation, or gastric outlet obstruction are the main complications of peptic ulcer disease (Narayanan et al, 2018).

Endoscopy is the gold standard for diagnosis of peptic ulcer disease (Lanas  and Chan, 2017). However, since H. Pylori infection is the most common cause of peptic ulcer disease,  a test and treat strategy with non-invasive tests (such as urea breath test) may be performed in patients under the age of 50-55 years old. In older patients a upper gastrointestinal endoscopy is recommended to exclude or confirm disease (Lanas and Chan 2017).

The initial management consists of acid suppression treatment and elimination of risk factors (Sverdén et al, 2019). Lifestyle measures, such as healthy eating, weight loss (if obese), avoiding trigger foods, eating smaller meals, eating the evening meal 3–4 hours before going to bed, raising the head of the bed, smoking cessation, and reducing alcohol consumption may improve symptoms. Assess the patient for stress, anxiety, or depression, as these conditions may exacerbate symptoms (NICE, 2019).

Endoscopically confirmed peptic ulcers that are not caused by H. Pylori are treated with proton pump inhibitors (PPI). The chronic usage of PPI should be closely balanced with their side effects which are linked to an increased risk of fracture, cardiovascular events, clostridium difficile infection, low magnesium, low Vitamin B12 levels, dementia and gastric cancer (Sverdén et al, 2019).

The treatment for peptic ulcers depends on the main cause. Eradication of H. Pylori infection alone is sufficient to heal peptic ulcers and to prevent relapse. However, successful treatment can be a challenge due to antibiotic resistance (Lanas and Chan, 2017). The first line therapy is triple therapy. This consists of proton pump inhibitors and 2 antibiotics. If triple therapy is not successful there are additional antibiotic and combined therapies that can be used in clinical practice (Lanas and Chan 2017; NICE, 2019). Patients should be reviewed after 6 to 8 weeks of starting eradication therapy and also have a repeat endoscopy 6–8 weeks after treatment to confirm ulcer healing (NICE 2019).

Drugs that induce peptic ulcers, such as NSAIDs, aspirin, bisphosphonates, immunosuppressive agents (e.g. corticosteroids), potassium chloride, selective serotonin reuptake inhibitors (SSRIs) and recreational drugs such as crack cocaine should be reviewed and stopped, if clinically appropriate (NICE, 2019).

Peptic ulcer disease usually occurs in the stomach and/or duodenum. Establishing the main cause is essential for successful management. The treatment is predominantly pharmaceutical although lifestyle measured should be considered where appropriate. Most patients will be prescribed with a PPI. Antibiotics are needed if the main cause is H. Pylori infection. Signs and symptoms should not be ignored as timely intervention will prevent serious complication. 

References

Sverdén E, Agréus L, Dunn JM, Lagergren J. Peptic ulcer disease. BMJ. 2019;367:l5495. https://doi.org/10.1136/bmj.l5495. 

National Institute for Health and care Excellence. 2019. Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management. Peptic ulcers disease.  https://www.nice.org.uk/guidance/cg184/ifp/chapter/peptic-ulcer (accessed 3 January 2023)

Lanas A, Chan FKL. Peptic ulcer disease. Lancet. 2017;390(10094):613-624. https://doi.org/10.1016/S0140-6736(16)32404-7

Dunlap, J. & Patterson, S. Peptic Ulcer Disease. Gastroenterology Nursing. 2019; 42(5), 451-454. https://doi.org/10.1097/SGA.0000000000000478

Narayanan M, Reddy KM, Marsicano E. Peptic Ulcer Disease and Helicobacter pylori infection. Mo Med. 2018;115(3):219-224.

Dittrich L, Schwenninger MV, Dittrich K et al. Marginal ulcers after laparoscopic Roux-en-Y gastric bypass: analysis of the amount of daily and lifetime smoking on postoperative risk. Surg Obes Relat Dis. 2020;16(3):389-396. https//doi.org/10.1016/j.soard.2019.11.022.