Peptic ulcer disease (PUD) occurs when an open sore, called an ulcer, develops in the lining of the stomach or the first part of the small intestine (duodenum). Ulcers in the stomach are called gastric ulcers, while ulcers in the duodenum are called duodenal ulcers.

Peptic ulcer disease is different from gastritis. Gastritis refers to inflammation of the stomach lining, while a peptic ulcer is a deeper area of damage in which the lining has actually broken down and formed an open sore. Gastritis may occur without an ulcer, although some of the same conditions—particularly H. pylori infection and NSAID use—can contribute to both.

What causes it?

The stomach normally contains strong acid and digestive enzymes. A protective mucus barrier helps prevent these substances from damaging the stomach and duodenal lining. Ulcers develop when this protective system is disrupted or the lining becomes particularly vulnerable to injury.

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Common causes are:
 

1. H. pylori infection

2. Nonsteroidal anti-inflammatory drugs (NSAIDs)

Risk increases with:

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• Higher doses

• Longer duration of treatment

• Older age

• Previous peptic ulcer or gastrointestinal bleeding

• Taking more than one NSAID

• Concurrent anticoagulant or antiplatelet therapy

• Corticosteroid use

• H. pylori infection

 

Less common causes of peptic ulcers include:

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• Certain medications

• Severe physiological illness

• Crohn disease involving the stomach or duodenum

• Certain infections in immunocompromised patients

• Zollinger-Ellison syndrome, a rare condition involving tumors producing excessive gastrin acid

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What Are the Symptoms?

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Some peptic ulcers cause no symptoms.

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• Burning, aching, or gnawing pain in the upper abdomen

• Indigestion

• Upper abdominal discomfort

• Nausea

• Bloating

• Feeling full quickly

• Reduced appetite

• Fatigue

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Meal-related patterns:

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Gastric ulcer

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Pain classically worsens shortly after eating, often within about 15–30 minutes, because food stimulates gastric acid secretion and distends the stomach.

Eat → pain worsens relatively soon

Some patients may therefore eat less and lose weight.

 

Duodenal ulcer

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Pain classically occurs when the stomach is relatively empty, often 2–5 hours after eating or at night. Eating or taking an antacid may temporarily relieve the discomfort because food buffers gastric acid before acidic contents subsequently enter the duodenum.

Eat → pain improves → several hours later pain returns

Some patients describe waking during the night with burning or gnawing epigastric pain.

 

Gastritis

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Gastritis is less predictable. It commonly causes burning, aching, or discomfort in the upper abdomen, which may be worse with eating, better with eating, or unrelated to meals. Other symptoms such as nausea, bloating, early satiety, or loss of appetite may be more prominent.

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Symptoms may occur when the stomach is empty, after meals, or during the night.

The relationship between eating and ulcer pain can vary and is not reliable enough to determine whether an ulcer is gastric or duodenal.

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Complications

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Slow bleeding causing iron-deficiency anemia, producing symptoms such as:

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• Fatigue

• Weakness

• Pale skin

• Shortness of breath with activity

• Dizziness

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Heavy bleeding, causing signs like:

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• Black, sticky, tar-like stools (melena)

• Vomiting blood

• Vomit that resembles coffee grounds

• Dizziness or fainting

• Rapid heart rate

• Weakness

 

*Significant gastrointestinal bleeding is a medical emergency

 

Ulcer Perforation

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An ulcer can cause a hole in the GI tract leading to GI contents leaking into the abdominal cavity and causing severe inflammation and infection.

 

Symptoms may include:

• Sudden, severe abdominal pain

• A rigid or extremely tender abdomen

• Rapid heart rate

• Weakness or fainting

• Severe illness

 

*A perforated ulcer is a medical emergency.

 

Gastric Outlet Obstruction

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Inflammation, swelling, or scarring from an ulcer near the stomach outlet can interfere with food leaving the stomach.

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Symptoms may include:

• Recurrent vomiting

• Feeling full after eating very little

• Abdominal bloating

• Weight loss

• Dehydration

 

What are some diagnostic tests?

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-CBC suggesting iron-deficiency anemia

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-Upper gastrointestinal endoscopy (EGD) is the most definitive test for directly identifying a peptic ulcer. A camera is inserted into the mouth and the provider can take biopsies, treat, and visually inspect inside the gut. 

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-Urea Breath Test or Stool Antigen Test- can detect active H. pylori infection and commonly used for initial diagnosis and to confirm eradication after treatment.

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-Biopsy for H. Pylori

 

-Blood Antibody Testing - Blood tests can detect antibodies against H. pylori, but antibodies may remain positive long after the infection has disappeared.

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*Certain medications can suppress H. pylori and cause a false-negative breath or stool test. For accurate testing, patients are commonly instructed to avoid:

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• Proton-pump inhibitors (PPIs) for approximately 2 weeks

• Antibiotics for approximately 4 weeks

• Bismuth-containing medications for approximately 4 weeks

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How Are Peptic Ulcers Treated?

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Treatment depends on the cause.

 

-Proton-Pump Inhibitors (PPIs) - PPIs strongly reduce stomach acid and allow the damaged lining to heal.

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-Treating H. pylori - treatment generally includes:

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• A proton-pump inhibitor

• Antimicrobial medications (tetracycline, metronidazole)

• Sometimes bismuth

 

The exact regimen depends on factors such as previous antibiotic exposure, allergies, local antibiotic resistance, and other patient-specific considerations. Eradication should be confirmed after 4 weeks of completing treatment.

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- Reconsidering medication changes - Patients should not discontinue prescribed aspirin, anticoagulants, or other important medications without discussing the risks and benefits with their healthcare provider.

 

-Other recommendations include:

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• Avoid unnecessary NSAID use

• Avoid or stop smoking

• Limit or avoid alcohol if it worsens symptoms

• Take prescribed ulcer medications correctly

• Complete the entire H. pylori treatment regimen when prescribed

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