Curriculum · Gastroenterology
Peptic ulcer disease
What it is
Peptic ulcer disease is an ulcer of the stomach or the duodenum, and where it sits shows in the story the patient tells:
- Gastric ulcer: epigastric pain occurs or worsens shortly after food intake
- Duodenal ulcer: epigastric pain occurs at hunger or midnight, and is relieved by food
Most PUD is caused by H. pylori infection or NSAID use, and all patients with PUD should be tested for H. pylori regardless of NSAID use. The gastric ulcer is typically located along the lesser curvature and goes with weight loss; the duodenal ulcer goes with weight gain, and its pain is nocturnal. Read from the timing, epigastric pain related to eating points to a gastric ulcer, while pain 2 to 3 hours after eating is more likely caused by a duodenal ulcer.
Causes and risk
H. pylori and NSAIDs are the two. After them:
- Zollinger-Ellison syndrome, that is gastrinoma, is a rare but important cause of refractory or multiple PUD, and serum gastrin level is the screening test. Refractory peptic ulcer disease with hypercalcemia and low serum phosphorus is MEN1: the ulcer from the gastrinoma, and the hypercalcemia with low phosphorus from hyperparathyroidism.
- Dual antiplatelet therapy, aspirin and clopidogrel after PCI, increases the chance of a peptic ulcer bleed.
A selective COX-2 inhibitor provides no better gastric protection than a nonselective NSAID plus a PPI, so it is not a way out.