Source: Berardi RR, Fugit RV. Peptic
Ulcer Disease. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells
BG, Posey LM, eds. Pharmacotherapy: A Pathophysiologic
Approach. 8th ed. http://accesspharmacy.com/content.aspx?aid=7977732.
Accessed June 23, 2012.
- A group of ulcerative disorders of the upper gastrointestinal
(GI) tract that require acid and pepsin for formation.
- Ulcers occur in presence of acid and pepsin when various
factors disrupt normal mucosal defense and healing mechanisms.
- Common causes:
pylori (HP) infection
- Nonsteroidal anti-inflammatory drugs (NSAIDs)
- Critical illness (stress-related mucosal damage)
- Uncommon causes:
- Hypersecretion of gastric
acid (Zollinger-Ellison syndrome)
- Viral infections
- Radiation therapy
- Cancer chemotherapy
- Medical illnesses (cirrhosis, chronic kidney disease)
- Alterations in mucosal defense most important factors
in ulcer formation.
- HP infection causes release of enzymes (urease, lipases, proteases)
that cause gastric inflammation and mucosal injury.
- NSAIDs cause gastric mucosal damage by:
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.
- 500,000 new cases and 4 million ulcer recurrences per
year in United States.
- Incidence of duodenal ulcers decreasing but incidence of gastric
- Gastric ulcers are slightly more common in men than women.
- Duodenal ulcers most common between ages 30–55; gastric
ulcers most common between ages 55–70.
- HP infection
- NSAID use
- Critical illness
- Epigastric or abdominal pain described as burning, vague
discomfort, fullness, or cramping.
- Nocturnal pain may awaken patients from sleep.
- Pain from duodenal ulcers often occurs 1–3 hours
after meals and usually relieved by food, whereas food may aggravate
gastric ulcer pain.
- Heartburn, belching, and bloating often accompany pain.
- Nausea, vomiting, and anorexia more common in gastric than
- Absence of pain does not preclude ulcer diagnosis, especially
in elderly who may present with silent ulcer complication.
- Complications include:
- Upper GI bleeding
- Penetration into adjacent structure
- Gastric outlet obstruction
- Bleeding may be occult or present as melena or hematemesis.
Means of Confirmation
- Physical examination may reveal epigastric tenderness.
- Urea breath test (UBT), serologic antibody detection tests,
and stool antigen test used to diagnose HP infection.
- Hematocrit, hemoglobin, and stool guaiac tests used to detect
- GI radiography has been largely supplanted by endoscopy.
- Upper GI endoscopy provides more accurate diagnosis than
radiography and permits direct visualization of ulcer.
- Functional dyspepsia
- Gastritis from NSAIDs, alcohol, stress, or HP
- Biliary disease or pancreatitis
- Gastroesophageal reflux disease (GERD)
- Indigestion from overeating, high-fat foods, coffee
- Gastric or pancreatic cancer
- Angina pectoris
- Relieve ulcer pain.
- Eradicate HP if present.
- Heal ulcer.
- Prevent ulcer recurrence.
- Reduce ulcer-related complications.
- Employ cost-effective therapy.
- Figure 1: Algorithm for evaluation and management of patient
with dyspeptic or ulcer-like symptoms