Peptic ulcer disease

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Peptic ulcer disease (PUD) results in an ulcer (a breach in the mucosa which extends into the submucosa or beyond) in the stomach or small intestines caused by acid. Ulcers are the result of a misbalance between the aggressive factors and protective factors tending towards the aggressive factors. Aggressive factors include acid and pepsin. If there is an increase in the aggressive factors, there is an associated increase in duodenal ulcers. Protective factors include bicarbonate, mucin, and the blood supply. A decrease in protective factors leads to gastric ulcers.

Peptic ulcer disease refers to chronic, usually solitary ulcers that occur in the distal stomach (antrum and pylorus) and duodenum. In Canada, approximately 400 000 people have peptic ulcers and 35 000 new cases are diagnosed each year. PUD tends to occur in middle-aged to older people and is more common in men than women (3:1 for duodenal ulcers and 2:1 for gastric ulcers).

Helicobacter pylori is the most important environmental factor in duodenal ulcers (90-95% of cases), and a relatively important factor in gastric ulcers (30% of cases). It can be considered a "designer bug" because of its amazing ability to live in the stomach. It can be tested for with serology, gastric biopsy, or a C13 urea breath test.

Other environmental factors include the ingestion of aspirin and nonsteroidal antiinflammatory drugs (NSAIDs), and cigarette smoking.

Peptic ulcers are typically chronic, single and have a punched-out appearance, unlike the irregular nodular appearance of an ulcerating cancer. Most gastric ulcers are along the lesser curvature of the antrum and most duodenal ulcers occur in the first part of the duodenum.

PUD usually causes epigastric pain related to eating. An ulcerating adenocarcinoma can masquerade as a seemingly benign peptic ulcer on both x-ray and endoscopic visualization, and therefore it is important for the endoscopist to biopsy gastric ulcers so that the pathologist can rule out malignancy.