Peptic Ulcer Disease (PUD)

What is Peptic Ulcer Disease?

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Peptic ulcer disease occurs mainly in the stomach or proximal duedenum.

Rarely, however, peptic ulcers can also occur in the oesophagus, jejunum (in Zollinger Ellison syndrome) or sometimes in a Meckel's diverticulum.

A: Stomach
B: Duodenum
C: Oesophagus

Statistics on Peptic Ulcer Disease?

Peptic ulcers are common, occurring in some 10-15% of the population at any one time, with duodenal ulcers being four times more common than gastric ulcers. PUD is more common in men (four times) and more common in elderly people. Ulcer rates are declining for young men and increasing for older individuals - since non-steroidal anti-inflammatory drugs (NSAIDS) are becoming a more prevalent cause with the other major cause, Helcobacter pylori infection being readily treated.

Risk Factors for Peptic Ulcer Disease

The two main causes of PUD are H. pylori infection and prolonged NSAID use. Peptic ulceration is also associated with smoking (impairs mucosal healing), excess alcohol hyperparathyroidism/ hypercalcaemia, Zollinger Ellison syndrome, excessive corticosteroid use, and stress.

Progression of Peptic Ulcer Disease

Patients may present with the clinical features listed. Peptic ulcers are chronic and recurrent lesions. Untreated, peptic ulcers can take around 15 years to heal but they heal quickly with present day therapies. Treating the cause or removing the exacerbating factor should be curative and patients can resume normal activity. The most important complications are perforation of the ulcer, obstruction due to excessive growth of fibrous tissue with stricture formation, and haemorrhage. These acute complications can be serious and require immediate emergency surgery.

How is Peptic Ulcer Disease Diagnosed?

The only labaratory finding may be of iron-deficiency anaemia.

Prognosis of Peptic Ulcer Disease

With removal of the causative factor when appropriate (e.g. NSAID use) and the use of appropriate treatment - H. Pylori eradication therapy, Proton Pump Inhibitors, most peptic ulcers heal within a few weeks. The complications of PUD can be associated with significant morbidity, and acute presentations with haemorrhage and perforation can be associated with significant mortality (up to 25%), however, with the early introduction of appropriate treatment these are now much less common. PUD is not considered to be associated with a risk of cancer, although cancers can ulcerate and be mistaken for peptic ulcers.

How is Peptic Ulcer Disease Treated?

The mainstay of treatment is eradicating H. Pylori when present and treating the cause - e.g. stopping of NSAID use if excessive.

Ulcers associated with H. pylori

Eradicating H. pylori is associated with healing rates of over 90% and prevents re-occurrence unless reinfection occurs. The usual treatment is "triple therapy" - with a proton pump inhibitor, and two antibiotics against H. Pylori.

Ulcers not associated with H. pylori

Usually associated with excessive use of NSAIDS. Therefore, stop NSAID or other causative agents, if possible and give acid suppressing drugs (H2 blocker or PP inhibitor). This will heal 80%-90% of ulcers over two months.

Antacids and antireflux methods (decrease weight, stop smoking, decrease alcohol, raise bed head, small regular meals, avoid hot drinks and eating less than 3 hours before bed) may also be used to compliment the above medical management.

Complications (haemorrhage, perforation, gastric outlet obstruction) are managed in hospital with appropriate resuscitation, and definitive management which usually requires surgery and/or endoscopy.

Peptic Ulcer Disease References

Braunwald, Fauci, Kasper, Hauser, Longo, Jameson. Harrison's Principles of Internal Medicine. 15th Edition. McGraw-Hill. 2001
Cotran, Kumar, Collins 6th edition. Robbins Pathologic Basis of Disease. WB Saunders Company. 1999.
Haslet C, Chiliers ER, Boon NA, Colledge NR. Principles and Practice of Medicine. Churchill Livingstone 2002.
Hurst JW (Editor-in-chief). Medicine for the practicing physician. 4th edition Appleton and Lange 1996.
Kumar P, Clark M. CLINICAL MEDICINE. WB Saunders 2002
Longmore M, Wilkinson I, Torok E. OXFORD HANDBOOK OF CLINICAL MEDICINE. Oxford University Press. 2001
McLatchie G and LEaper DJ (editors). Oxford Handbook of Clinical Surgery 2nd Edition. Oxford University Press 2002.
MEDLINE Plus
Raftery AT Churchill's pocketbook of Surgery. Churchill Livingsone 2001.
Tjandra, JJ, Clunie GJ, Thomas, RJS,; Textbook of Surgery, 2nd Ed, Blackwell Science, Asia. 2001.