Peptic Ulcer Disease

Introduction

Peptic ulcer disease refers to the formation of ulcers in the mucosal lining of the stomach (gastric ulcers) or duodenum (duodenal ulcers). Duodenal ulcers are approximately four times more common than gastric ulcers. The main causes are Helicobacter pylori infection and non-steroidal anti-inflammatory drug (NSAID) use.

Peak Incidence

• Duodenal ulcers: Most common between 30 and 50 years.
• Gastric ulcers: Typically affect individuals aged over 50 years.

Pathophysiology

• Peptic ulcers result from an imbalance between mucosal protective factors (e.g. mucus, bicarbonate, prostaglandins) and damaging factors (e.g. gastric acid, H. pylori, NSAIDs).
• H. pylori infection increases acid production and weakens mucosal defences.
• NSAIDs inhibit prostaglandin synthesis, reducing mucosal protection.

Symptoms

• Epigastric pain or discomfort.
• Nausea and vomiting.
• Dyspepsia (indigestion).
• Loss of appetite.

Perforated Peptic Ulcer (Complication)

• Sudden onset of severe epigastric pain, often radiating to the shoulders.
• Generalised abdominal pain may follow as peritonitis develops.

Signs

• Epigastric tenderness on palpation.
• Features of gastrointestinal bleeding:
  • Haematemesis.
  • Melaena.
• Features of anaemia:
  • Pallor.
  • Fatigue.

Signs of Perforation

• Rigid, board-like abdomen.
• Rebound tenderness and guarding.
• Tachycardia and hypotension (especially if in shock).
• Reduced or absent bowel sounds.

Diagnosis

Initial Investigations

• H. pylori testing:
  • Urea breath test (preferred).
  • Stool antigen test.

Definitive Diagnosis

• Oesophagogastroduodenoscopy (OGD): Gold standard for diagnosis.
  • Allows direct visualisation and biopsy (especially for gastric ulcers to exclude malignancy).

Blood Tests

• Full blood count – To assess for anaemia.
• Serum gastrin – If Zollinger-Ellison syndrome is suspected.

Imaging

• Erect chest X-ray – To detect perforation (free air under diaphragm).
• Abdominal CT scan – More sensitive for detecting pneumoperitoneum and the site of perforation.
• Serum lactate and inflammatory markers (e.g. CRP, WCC) – To assess for sepsis and systemic inflammation.

Red Flag Features – 2-Week Wait Referral (UK)

• Any dysphagia.
• Aged ≥55 years with weight loss and any of the following:
  • Upper abdominal pain.
  • Reflux.
  • Dyspepsia.

Complications

1. Bleeding (Most common)

• Signs:
  • Haematemesis.
  • Melaena.
  • Tachycardia, hypotension (in severe cases).
• Management:
  • ABC approach.
  • IV proton pump inhibitors (PPIs).
  • Endoscopic haemostasis (e.g. clipping, coagulation, adrenaline injection).
  • Interventional radiology or surgery if endoscopy fails.

2. Perforation (Surgical emergency)

• Symptoms:
  • Sudden severe epigastric pain.
  • Syncope may occur.
• Diagnosis:
  • Erect chest X-ray (free air).
  • CT scan – Confirms location.
• Management:
  • Urgent laparoscopic surgical repair.

3. Pyloric Stenosis

• Caused by chronic ulceration and scarring.
• Symptoms:
  • Early satiety.
  • Bloating.
  • Vomiting (especially postprandial).
• Management:
  • Endoscopic dilatation or surgical intervention.

Management

General Measures

• Lifestyle advice:
  • Avoid NSAIDs.
  • Stop smoking and alcohol.
  • Reduce caffeine and spicy food intake.
  • Manage psychological stress.

H. pylori-Negative Ulcers

• High-dose PPI therapy (e.g. omeprazole, lansoprazole) for 4–8 weeks.

H. pylori-Positive Ulcers

• Eradication therapy:

  • Triple therapy: PPI + amoxicillin + clarithromycin (or metronidazole if penicillin-allergic) for 7–14 days.
  • Confirm eradication with a repeat urea breath test or stool antigen test after 4 weeks (and at least 2 weeks off PPI).