Peptic Ulcer Disease
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Direct answer
Peptic ulcer disease is a mucosal break in the stomach or duodenum that exceeds the protective barrier, most commonly caused by Helicobacter pylori infection or NSAID use. Duodenal ulcers typically cause epigastric pain two to three hours after meals that is relieved by food, while gastric ulcer pain is often worsened by eating and requires biopsy to exclude malignancy. Management rests on three pillars: proton pump inhibitor therapy to heal the ulcer, eradication of Helicobacter pylori, and withdrawal or protection against NSAIDs.
What you must remember
- Duodenal versus gastric: duodenal ulcers are more common and tied to acid hypersecretion, whereas gastric ulcers occur with normal or low acid output and need biopsy.
- Causes: Helicobacter pylori and NSAIDs account for most cases; low-dose aspirin, corticosteroids and smoking add risk, and Zollinger-Ellison syndrome is considered for refractory or multiple ulcers.
- Complications: haemorrhage is the commonest, followed by perforation, gastric outlet obstruction and penetration into the pancreas.
- Alarm features: melaena, haematemesis, weight loss, dysphagia, anaemia and vomiting prompt endoscopy rather than empirical treatment.
- Acid suppression: a proton pump inhibitor is given once or twice daily for about four to eight weeks to heal an active ulcer; H2 receptor blockers heal ulcers less reliably.
- NSAID protection: a proton pump inhibitor co-prescribed with an NSAID reduces ulcer risk, and misoprostol is an alternative.
- Surveillance: gastric ulcers are repeated at endoscopy after treatment to document healing and exclude malignancy.
A tale of two ulcers
A 45-year-old man takes an over-the-counter combination of diclofenac and paracetamol for back pain. He develops epigastric pain two hours after meals that eases with food.
- Read the pain pattern: epigastric pain two hours after meals that eases with food suggests a duodenal ulcer, but the pattern is not reliable enough to diagnose the site.
- Endoscope and test for H pylori: endoscopy shows a duodenal ulcer in this patient, and H pylori testing is positive.
- Treat and stop the NSAID: a proton pump inhibitor is given, the NSAID is stopped, and a bismuth-based eradication regimen follows, with reassessment after the course.
- Biopsy a gastric ulcer: a 68-year-old woman with dull epigastric pain worsened by eating, weight loss of several kilograms and mild anaemia has a gastric ulcer with irregular edges, so biopsy is taken from the margin because adenocarcinoma can mimic the lesion.
- Confirm healing: she needs repeat endoscopy after eight to twelve weeks to confirm healing, while acid suppression and eradication continue.
The two cases show that pain pattern guides suspicion, while biopsy decides whether the ulcer is benign. The history also covers alcohol, smoking and steroid use, because these risks compound with NSAIDs and each one is a modifiable factor in the next course of treatment.
Where the exam tries to catch you
Examiners pick out the same few errors.
- Trap: advising biopsy for every ulcer. Correct: gastric ulcers need biopsy at the first endoscopy, but duodenal ulcers almost never harbour malignancy and do not need routine biopsy.
- Trap: testing for H pylori within two weeks of stopping a proton pump inhibitor. Correct: the urea breath test and stool antigen can become falsely negative, so they should be avoided for about two weeks.
- Trap: trusting the pain pattern to locate the ulcer. Correct: endoscopy is the diagnostic step, since the pattern is not reliable enough to diagnose the site.
- Trap: reaching for an antacid when dyspepsia follows analgesic use. Correct: in India, self-medication with over-the-counter NSAID combinations is widespread, so think of drug-induced ulcer first.
Frequently asked questions
Why must gastric ulcers be biopsied while duodenal ulcers usually do not?
Gastric ulcers carry a risk of underlying gastric adenocarcinoma, so biopsy at the first endoscopy and repeat endoscopy after treatment are standard. Duodenal ulcers almost never harbour malignancy and do not need routine follow-up endoscopy if there are no alarm features.
Which test should be avoided within two weeks of a proton pump inhibitor for Helicobacter pylori?
The urea breath test and stool antigen test can be falsely negative after a proton pump inhibitor, so they should be avoided for about two weeks after stopping the drug. Serology is unaffected by acid suppression and can be used when other tests are unsuitable.
What is the first-line drug class for healing peptic ulcers?
Proton pump inhibitors are the first-line drug class for healing peptic ulcers, given once or twice daily for typically four to eight weeks. Eradicating Helicobacter pylori is then essential to prevent recurrence.
Which ulcers suggest Zollinger-Ellison syndrome?
Refractory, multiple or unusually located ulcers, especially in the jejunum, suggest Zollinger-Ellison syndrome caused by a gastrin-secreting tumour. Serum gastrin is interpreted off proton pump inhibitors where feasible, because these drugs themselves raise gastrin levels.