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SOURCE

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Source: Love BL, Mohorn PL. Peptic ulcer disease and related disorders. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy: A Pathophysiologic Approach. 10th ed. New York, NY: McGraw-Hill; 2017. http://accesspharmacy.mhmedical.com/content.aspx?bookid=1861&sectionid=146058912. Accessed August 3, 2017.

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CONDITION/DISORDER SYNONYMS

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  • Peptic Ulcer Disease (PUD)

  • Ulcers.

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DEFINITION

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  • A group of ulcerative disorders of the upper gastrointestinal (GI) tract that require acid and pepsin for formation.

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ETIOLOGY

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  • Ulcers occur in presence of acid and pepsin when various factors disrupt normal mucosal defense and healing mechanisms.

  • Common causes:

    • Helicobacter pylori (HP) infection.

    • Nonsteroidal anti-inflammatory drugs (NSAIDs)

    • Critical illness (stress-related mucosal damage)

  • Uncommcon causes of chronic peptic ulcer.

    • Idiopathic (non-H. pylori, non-NSAID peptic ulcer)

    • Hypersecretion of gastric acid (Zollinger–Ellison syndrome)

    • Viral infections (eg, cytomegalovirus)

    • Vascular insufficiency (eg, crack cocaine associated)

    • Radiation therapy.

    • Chemotherapy (eg, hepatic artery infusions)

    • Infiltrating disease (eg, Crohn disease)

    • Uncommon causes of chronic peptic ulcer.

  • Diseases and medical conditions associated with chronic peptic ulcer.

    • Cirrhosis.

    • Chronic renal failure.

    • Chronic obstructive pulmonary disease.

    • Cardiovascular disease.

    • Organ transplantation.

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PATHOPHYSIOLOGY

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  • Alterations in mucosal defense most important factors in ulcer formation.

  • HP infection causes release of enzymes (urease, lipases, and proteases) that cause gastric inflammation and mucosal injury.

  • NSAIDs cause gastric mucosal damage by:

    • Direct irritation of gastric epithelium.

    • Systemic inhibition of endogenous mucosal prostaglandin synthesis.

  • Cigarette smoking impairs ulcer healing and may be associated with ulcer-related GI complications.

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EPIDEMIOLOGY

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  • Epidemiology of PUD is complicated and the prevalence is difficult to estimate given the variability in H. pylori infection, NSAID use, and cigarette smoking.

  • Mortality rates are higher among those older than or 65 years and in males compared to females.

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RISK FACTORS

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  • HP infection.

  • NSAID use.

  • Zollinger–Ellison syndrome.

  • Smoking.

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CLINICAL PRESENTATION

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SIGNS AND SYMPTOMS
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  • General.

  • Mild epigastric pain or acute life-threatening upper GI complications.

  • Symptoms.

    • Abdominal pain that is often epigastric and described as burning but may present as vague discomfort, abdominal fullness, or cramping.

    • A typical nocturnal pain that awakens the patient from sleep (especially between 12 and 3 AM).

    • The severity of ulcer pain varies from patient to patient and may be seasonal, occurring more frequently in the spring or fall; episodes of discomfort usually occur in clusters, lasting up to a few weeks and followed by a pain-free period or remission lasting from weeks to years.

    • Changes in the character of the pain may suggest the presence of complications.

    • Heartburn, belching, and bloating often accompany the pain.

    • Nausea, vomiting, and anorexia are more common for patients with gastric ulcer than with duodenal ulcer but may also be signs of an ulcer-related complication.

  • Signs.

    • Weight loss associated with nausea, vomiting, and anorexia.

  • Complications include:

    ...

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