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Approximately 10% of Americans develop chronic peptic ulcer disease (PUD) during their lifetime.1 An estimated 60% to 100% of ulcers recur within 1 year of healing with conventional treatment.1 In the United States roughly 30% to 40% of the population is infected with Helicobacter pylori (H. pylori), but not all will develop PUD.2 Most people acquire the infection during childhood.

Peptic ulcers are lesions in the stomach or duodenum that extend deeper into the gastrointestinal (GI) tract than other acid related disorders. These lesions develop in response to damage by gastric acid and pepsin. Gastric ulcers can occur anywhere in the stomach, but most are located on the lesser curvature. In contrast, duodenal ulcers occur in the first part of the duodenum. PUD is commonly divided into three forms: H. pylori induced, nonsteroidal anti-inflammatory drug (NSAID) induced, and stress related mucosal damage (SRMD). Helicobacter pylori is a spiral shaped, gram-negative bacteria that resides in the gastric epithelium and produces urease. The exact mechanism of gastric injury is unknown, but some possibilities include: the production of a cytotoxin, an increase gastric acid production and alterations in the host immune response.3

Damage from NSAIDs can occur by two mechanisms: direct irritation of the gastric epithelium and systemic inhibition of prostaglandin (cyclooxygenase-1 [COX-1] and cyclooxygenase-2 [COX-2]) synthesis. Up to 25% of chronic NSAID users will develop ulcer disease.4

Stress ulcers are superficial lesions that form in the mucosal layer of the stomach within hours of major stressful event (trauma, burns, surgery, organ failure, or sepsis). The most common cause of gastrointestinal bleeding in the intensive care unit is stress ulcers and the presence of a GI bleed is associated with a fivefold increase in mortality. The incidence of stress related mucosal bleeding (SRMB) is 1% to 6%. SRMB can increase hospital stays and health care cost.5

Signs and Symptoms

The clinical presentation of PUD can vary but may include nonlocalized epigastric pain. Other symptoms of PUD include heartburn, belching, bloating, nausea, and anorexia. Pain due to a duodenal ulcer may be worse with an empty stomach (at night or between meals) and may be relieved by food. Helicobacter pylori infection is more commonly associated with duodenal ulcers, but can occur with gastric ulcers. Gastric ulcer pain may occur at any time or may be worsened with eating. NSAID use is associated with gastric ulcers. Both types of ulcers can occur in the absence of symptoms and this is especially true with gastric ulcers in the elderly.4 Patients can present with similar symptoms, therefore no one symptom can differentiate between H. pylori and NSAID-induced ulcers.


Upper GI radiography and upper endoscopy can be used to visualize the ulcer and diagnose PUD.6 Testing for H. pylori is recommended for patients with active ulcer disease, a past history ...

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